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REPORT SEPTEMBER 2017

Funding Models for Physician Assistants.Canadian and International Experiences

Funding Models for Physician Assistants: Canadian and International Experiences Kelly Grimes, Gabriela Prada, Yvonne James, Thy Dinh, and Jessica Brichta

Preface

This report reviews several funding sources for employing physician assistants (PAs), including the experience in the Canadian provinces of Manitoba and Ontario. International models include the United States, the United Kingdom, and the Netherlands. This report also provides insight on funding experiences from the perspective of several PAs in Ontario. PAs are employed in many settings in Canada. Informants in this report identified challenges with sustainable funding that contribute to job security in PA employment. Funding for PA employment is derived from several sources: provincial governments through demonstration projects, career start programs, and targeted clinical service funding in primary care and hospital settings; block funding such as academic speciality groups; or direct funding from physicians or hospitals. In comparing PA funding models and workforce planning, approaches vary considerably to reflect community need and wider health policy directions. Ideally, health care funding models should be cost-effective and sustainable while meeting system performance targets. Canada should explore means of optimizing funding models to better support the integration of PAs in its health care system to help meet these goals. Improved tracking of where and how PAs work and understanding of their benefits to society will help create opportunities to optimize the health care workforce through increased PA use.

To cite this report: Grimes, Kelly, Gabriela Prada, Yvonne james, Thy Dinh, and jessica Brichta. Funding Models for Physician Assistants: Canadian and International Experiences. Ottawa: The Conference Board of Canada, 2017.

©2017 The Conference Board of Canada* Published in Canada | All rights reserved | Agreement no. 40063028 | *incorporated as AERiC inc.

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®The Conference Board of Canada and the torch logo are registered trademarks of The Conference Board, inc. forecasts and research often involve numerous assumptions and data sources, and are subject to inherent risks and uncertainties. This information is not intended as specific investment, accounting, legal, or tax advice. The findings and conclusions of this report do not necessarily reflect the views of the external reviewers, advisors, or investors. Any errors or omissions in fact or interpretation remain the sole responsibility of The Conference Board of Canada.

CONTENTS

i EXECUTIVE SUMMARY

Chapter 1 1 introduction 6 Overview of Research Approach

Chapter 2 7 Health Service Provider funding Sources

Chapter 3 13 funding Models for Physician Assistant integration 14 The United States 20 The United Kingdom 25 The Netherlands 30 Manitoba 35 Ontario 40 Comparison of PA Funding Models Across Case Examples

Chapter 4 44 Ontario PA funding Experiences by Practice Setting 45 Primary Care 47 Emergency Medicine 49 Endocrinology 50 Orthopedic Surgery 51 Opportunities and Challenges

Chapter 5 53 Conclusion 55 Funding Models Need to Better Reflect Context 56 A Salaried Approach for Remuneration Is the Most Common and Likely Way Forward 56 Monitoring PA Work, as Well as Their Impact, Outcomes, and Efficiency, Is Essential 57 Communication About the Value of PAs Is Important Within a Strained Health Care System

Appendix A 58 Key informant interviews and Guide for Case Examples 59 Interview Guide Questions

Appendix B 62 Bibliography

AcknowledgementsThis report was researched and written by Kelly Grimes, Gabriela Prada, Yvonne James, Thy Dinh, and Jessica Brichta.

The authors want to thank the key informant interviewees who contributed to the development of the case examples. The authors would also like to thank the expert advisory committee that provided input on the methodology and reviews of this work. We thank them for their timely and valuable input. Committee members include:

• Owen Adams, Chief Policy Advisor, Canadian Medical Association• Dr. John Brewer, Medical Director of the Academic Family Health Team,

Civic Campus Ottawa Hospital (on behalf of the College of Family Physicians of Canada)

• Sean Brygidyr, Executive Director, Health Human Resource Planning Health Workforce Secretariat, Manitoba Health, Healthy Living and Seniors

• Danielle Fréchette, Executive Director, Royal College of Physicians and Surgeons of Canada

• Mario Gulin, Physician Assistant and Non-Commissioned Member, Senior Staff Officer, Canadian Forces Health Services Group Headquarters, Directorate of Medical Policy

• Tanya Knorren, Senior Consultant, Alberta Health Services• Lynne Nagata, Provincial Planner, Health Workforce Policy Branch, Ministry

of Health and Long-Term Care Ontario

The authors would also like to thank the external reviewers of this report:

• Kristen Burrows, Assistant Dean, McMaster Physician Assistant Education Program, Faculty of Health Sciences, McMaster University

• Dr. Maureen Gottesman, Medical Director, Physician Assistant Professional Degree Program, Faculty of Medicine, University of Toronto

• Dr. Roderick Hooker, Adjunct Professor of Health Policy, Northern Arizona University, Phoenix, Arizona

Carole Stonebridge, Principal Research Associate, The Conference Board of Canada, provided an internal review.

This research was funded by the Canadian Association of Physician Assistants (CAPA); the Royal College, Alberta Health Services; and the College of Family Physicians of Canada.

Additional research and publication funding was provided by the Centre for the Future of Health.

About the Centre for the Future of Health

The Centre for the Future of Health at The Conference Board of Canada is a recent merger between the Centre for the Advancement of Health Innovations and the Centre for Health System Design and Management. The Centre is a research centre and forum for leaders in the health arena to address complex issues and build capacity for strategic solutions. It aims to improve Canada’s health care system and commercialization capacity through innovation. The members of the Centre included the following organizations in 2015–16 and 2016–17.

• Alberta Health Services• AbbVie Canada• AstraZeneca Canada Inc.• GlaxoSmithKline Canada• Health Canada• Johnson & Johnson Inc.• Medavie Blue Cross• Medtronic Canada Ltd.• Merck Canada Inc.• Ontario Ministry of Health and Long-Term Care• Southlake Regional Health Centre• Stilco Corporation• Sykes Assistance Services Corporation• University of British Columbia

Disclaimer

The findings and conclusions of this report are entirely those of The Conference Board of Canada and do not necessarily reflect the views of the funder, advisory committee, or the reviewers. Any errors or omissions in fact or interpretation remain the sole responsibility of The Conference Board of Canada.

Find Conference Board research at www.e-library.ca.

EXECUTIVE SUMMARY

Funding Models for Physician Assistants: Canadian and International Experiences

At a Glance

• This report describes sources of funding where significant numbers of physician assistants (PAs) are working, offers case examples of health systems that have successfully integrated PAs domestically and abroad, and discusses next steps for research, policy, and practice.

• The United States provides PA remuneration through a discounted fee-for-service model, the United Kingdom pays PA salaries and has proposed a single investment model, and in the netherlands PA services can be billed to insurance companies and deducted from practice expenses.

• in Canada, Manitoba is shifting PA funding from hospitals to physician groups, while PA funding in Ontario comes from a number of different sources.

• Better leveraging of PAs can help address many of Canada’s health system goals, such as improved continuity of care, access, equity, and sustainability.

fUnDinG MODELS fOR PHYSiCiAn ASSiSTAnTSCanadian and international Experiences

Find Conference Board research at www.e-library.ca. ii

Innovation, patients first, interprofessional health care teams, sustainability, and capacity-building are but a few of the common terms now part of the Canadian health care lexicon. Health care system stakeholders, including patients, providers, policy-makers, decision-makers, and researchers, all want to imagine a new system that better meets the needs of an aging society (a key cost driver) but is also cost-effective to ensure sustainability and growth.

This research series provides a better understanding of the role and

impact of Canada’s 587 practising PAs.1 in various health care settings

across Canada, sources of funding in jurisdictions where significant

numbers of PAs are working are described. in addition, the report offers

case examples of health systems that have successfully integrated PAs

domestically and abroad, and discusses next steps for research, policy,

and practice.

This is the third report in this series by The Conference Board of

Canada. The first, Value of Physician Assistants: Understanding the

Role of Physician Assistants Within Health Systems,2 discussed the role

and impact of PAs in health care. The second report, Gaining Efficiency:

Increasing the Use of Physician Assistants in Canada,3 estimated

potential cost savings generated by increased PA use in primary care,

emergency care services, and orthopedics. The analysis showed that

task-shifting certain physician responsibilities to PAs could create cost

savings for the health care system, ranging from $22 million to more

than $1 billion between 2017 and 2030, depending on the level of PA

productivity. This third installment provides an overview of the various

funding sources used to integrate PAs in health systems and policy

considerations for the Canadian context. it focuses on different Canadian

funding models that have been used to support the integration of PAs

1 CAPA 2017 census data.

2 Grimes and Prada, Value of Physician Assistants.

3 Desormeaux and others, Gaining Efficiency.

Executive Summary | The Conference Board of Canada

Find Conference Board research at www.e-library.ca. iii

in health teams. Adoption and modification of funding models could

serve for exploring the scaling of PA services across the country.

Compared with other countries, Canada has a highly decentralized

system for the financing,4 funding,5 and delivery of health care services.

Provincial/territorial total health expenditures vary per capita. Canada

is often referred to as having 14 different health systems (provinces,

territories, and federal). internationally, Canada continues to be a high

health spender among Organisation for Economic Co-Operation and

Development (OECD) countries,6 although it is still ranked behind the

U.S. in terms of per capita spending. Canada ranks third in the world

in the average number of physician visits per capita, ahead of the U.S.,

U.K., and the netherlands.7 The health workforce implications of these

economic realities are significant, as supply will not meet the growing

demand for health services—the result of an aging population, a rise in

chronic disease, and other growth-affecting factors. interprofessional and

collaborative care teams help meet these heightened service demands,

and PAs can fill in service gaps.

International Experience With PAs

The U.S. employs the highest number of PAs in the world. PAs and nurse

practitioners (nPs) comprise 20 per cent of the U.S. clinician workforce,

and demand appears to be greater than supply.8 Each state regulates

the practice of PAs through licensure (by licensing them to practise under

a physician). A supervising physician must be named (at least on paper);

however, states do not require the physician to be physically present to

supervise.9 in the U.S., there are over 115,500 clinically active PAs,10

4 financing refers to how revenues are raised, such as through public sources like taxation or private sources such as employee health insurance plans, user charges, loans, and fees.

5 funding refers to how health care organizations and providers are paid to carry out their work. This includes remuneration of health providers, team-based models of care, organization-specific funding, or grants.

6 OECD, comprising 35 member countries from around the world, “promotes policies that will improve the economic and social well-being of people around the world.” OEDC, Members and Partners; About the OECD.

7 Canadian institute for Health information, National Health Expenditure Trends, 1975–2016.

8 Hooker, Brock, and Cook, “Characteristics of nurse Practitioners and Physician Assistants.” individual nursing and PA data were not isolated in this source.

9 Davis and others, “Access and innovation in a Time of Rapid Change.”

10 American Academy of Physician Assistants, PA Myth Busters.

The U.S. employs the highest number of PAs in the world.


Find Conference Board research at www.e-library.ca. iv

mainly in family medicine, medical subspecialties, surgery, and

emergency medicine.11 in the U.S., the Patient Protection and Affordable

Care Act, 201012 changed the landscape of providing care from a

specialist-centred system to a primary care one. The Act recognizes

PAs, nPs, and physicians as primary care providers and permits PAs

to lead patient-centred medical teams. Delivery models such as patient-

centred medical home and accountable care organizations are now more

commonplace. Thus, the health care payment system has also shifted,

with 30 per cent of traditional Medicare payments now going through

alternative payment models, such as bundled payments and accountable

care organizations. The PA median salary is US$95,000 (2015 dollars).

Remuneration from public payers (i.e., Medicare, Medicaid) for PA

services is provided through a discounted fee-for-service model

(i.e., 85 per cent of a physician’s fee schedule). nearly all private payers

cover PA services at a similar rate. PAs in the U.S. recertify every

10 years (recertification is mandatory for some states and optional

for others).

in the U.K. (England and Scotland), PAs (known as “physician

associates”13) have been providers of care within the national Health

Services (nHS) since 2006.14 As of 2017, approximately 400 PAs are

clinically active, initially to augment primary care practices.15 PAs are

not regulated; however, nHS is examining this issue further as part of a

wider policy approach. in the U.K., PA scope of practice is similar to

that of a junior physician.16 PAs are required to recertify every six years.

Thirty PA education programs in the U.K. are expected to graduate

3,200 PAs by 2020 and PA workforce planning includes meeting the

target of 1,000 primary care PAs by 2020. PA education expansion

has occurred in Wales and northern ireland. As of 2016, only 20 per

11 national Commission on Certification of Physician Assistants, 2015 Statistical Profile of Certified Physician Assistants by Specialty.

12 Patient Protection and Affordable Care Act, 2010.

13 in 2013, physician assistants were renamed physician associates because of nHS salary banding.

14 Aiello and Roberts, “Development and Progress of the United Kingdom Physician Associate Profession.”

15 ibid.

16 junior physicians in the U.K. are medical practitioners who have graduated with a Bachelor of Medicine or Bachelor of Surgery degree, and have started the UK foundation Programme. This is roughly equivalent to a post-graduate year one (PGY1) resident in Canada.

Thirty PA education programs in the U.K. are expected to graduate 3,200 PAs by 2020.


Find Conference Board research at www.e-library.ca. v

cent of PAs are recruited into primary care. Health Education England

is looking at additional investments in the PA workforce, as several

funding models are attempting to grow the PA supply. Health Education

England has proposed a single investment model that addresses local

needs and national policy to increase PAs. Communication has been

a key ingredient to garner PA support and integration. PAs are salaried

and their compensation is not linked to volume or type of patient seen.

nHS employers remunerate PAs in the range of £33,000 to £42,000 per

year (C$59,448 to $75,661) (2015 currency).17 PAs have been found to

decrease locum team expenses and contribute to a more stable and

economical workforce.

Like the U.K., the netherlands’ health system is run centrally, with the

national government determining and monitoring health care priorities,

legislation, and quality. Predicted physician shortages provided the

impetus for developing a PA workforce18 and the PA supply grew

from 4 PAs in 2001 to 1,000 over a 15-year period. five PA education

programs produce 150 graduates per year—projected to reach 200 by

2020. PAs work in all health care settings, from forensic to academic;

however, most are employed in hospitals in specialty practices,

followed by ambulatory primary care. in the netherlands, PA legislation

considers PAs independent health care providers who can bill insurance

companies for clinical services provided and do not require supervision

by a medical specialist. Dutch PAs work in collaboration with physicians.

The Advisory Committee on Medical Manpower Planning oversees

health workforce planning and has emphasized vertical substitution19

of physician work to PAs and nPs. Data show the largest PA increases

in general practice, gastroenterology, orthopedics, and internal medicine.

in terms of funding, insurance companies negotiate with boards of

hospitals for contracted services. PAs’ salaries are lower, so if they

can deliver the same service as a resident (e.g., junior doctor), the

hospital saves money. As of 2017, there are no set fees by insurance

companies for PAs. However, some insurance companies are requesting

17 Calculated using OECD’s purchasing power parities converter. OECD, Purchasing Power Parities.

18 Van den Driesschen and de Roo, “Physician Assistants in the netherlands.”

19 Vertical substitution is the delegation of tasks across professional boundaries, such as a pharmacist providing flu shots, a role traditionally done by physicians. Throughout this report, however, substitution is referred to as “task transfer.”

Dutch PAs work in collaboration with physicians.


Find Conference Board research at www.e-library.ca. vi

a special fee for PAs (such as .88 of a normal fee), so this may change.20

individual PAs negotiate their own salaries with their employer, with an

€80,000 (C$101,762)21 annual survey average. A 2015 change in the tax

system has facilitated task realignment and the integration of PAs by

allowing medical specialists to deduct these practice expenses.

PAs in Manitoba and Ontario

in Canada, 13.8 per cent of PAs are employed in Manitoba,22 and the

province has the longest history of integrating PAs into various models

of care—primarily surgical, emergency, and primary care. The PA

profession has been regulated in Manitoba since 2001, and PA allocation

is centralized with the government deciding what programs will receive

the new annual graduates (12 per year as of 2017). Each year, funds

earmarked for PAs flow to the Regional Health Authorities and then

to PAs. Manitoba remunerates PAs through salary. Physicians can bill

the government for services pursuant to the Physician’s Manual, which

may include PA services if they have been substantially involved in

the services rendered. However, a funding model option that allows

physicians to bill for PA services at a discounted rate to reduce health

system costs does not yet exist. The Manitoba government is supportive

of PAs in principle as they increase throughput (i.e., more patients are

seen, especially in high wait-time areas) and help physicians deal with

more complex tasks. Manitoba’s province-wide tracking system will play

an important role in the establishment of a dedicated source of funds

for PA employment, as the system will help determine if subsidizing

PA billing codes for specific tasks is feasible in the Canadian context.

Ontario is the province with the highest proportion of PAs (64.74 per

cent),23 and its two civilian educational programs produce 50 graduates

per year. The Canadian Armed forces (CAf) program is also located

in Ontario and produces some 25 additional graduates per year,

20 Key informant interviews.

21 Calculated using OECD’s purchasing power parities converter. OECD, Purchasing Power Parities.

22 Canadian Association of Physician Assistants, CAPA 21017 census data.

23 ibid.


Find Conference Board research at www.e-library.ca. vii

bringing the Ontario PA graduate total to approximately 75 per year

among the three programs. PAs in the CAf have clinical rotations

in civilian clinics and hospitals. Many military PAs retire with the

intention of practising in the public health care system. PAs in Ontario

are unregulated, and the province does not have an established PA

funding model, although eligible employers may be granted Career

Start Program or clinical services funding to support PA employment.

Ontario has established a Physician Assistant integration Working

Group to support initiatives that improve population health through the

integration of more physician assistants into Ontario’s health workforce.

Practice setting interviews with several PAs and supervising physicians

in the province uncovered a sentiment that, among some Ontario PAs,

unsustainable and unpredictable funding engenders insecurity and

turnover, irrespective of the practice setting or funding model of the

physicians with whom they work. Like other health care professionals,

some PAs work within multiple practices to maintain a full-time equivalent

(fTE) income while others choose to work part time at multiple sites

because of medical/career interests or for better work–life balance.

PAs working in large group practices with physicians in a physician fee-

for-service model reported being employed or more likely to be employed

in full-time positions than those in smaller practice settings and that the

sustainability of these positions was sometimes dependent on the PA

meeting service delivery quotas.

Areas of Further Investigation for PA Funding Models

The funding experience for PAs differs between the two largest provincial

PA employers (Manitoba and Ontario) highlighted in this report. Based

on the work conducted for this report, some of the key observations and

potential areas for further investigation include:

• ensuring funding models reflect a contemporary context, considering

the benefits and challenges of a salaried approach to remuneration;

Many military PAs retire with the intention of practising in the public health care system.


Find Conference Board research at www.e-library.ca. viii

• tracking the PA profession in all provinces and the benefits that PAs

provide from a population health and systems efficiency perspective

(taking into account other factors, such as multiple providers and costs);

• improving awareness of the role and value of PAs among patients and

other health care providers.

As population health needs become more complex and the demand

for services increases, optimizing health care workforce configurations,

service delivery approaches, and funding models becomes increasingly

important. PAs are an existing and largely untapped health provider

group that could be better leveraged to narrow health care service

gaps in Canada. PAs are trained as effective health professionals

in collaborative relationships with physicians and interprofessional

teams. Leveraging PAs can help address many of Canada’s health

system goals, such as improved continuity of care, access, equity,

and sustainability.


CHAPTER 1

Introduction

Chapter Summary

• PAs in Canada have a long history of being employed in the military, and the Canadian PA supply and workforce has increased notably over the past decade.

• This series engages in practical dialogue for the future expansion of PA roles within Canada.

• This third report reviews both national and international funding sources for PAs and discusses considerations by profiling three countries—the United States, the United Kingdom, and the netherlands.

• it also highlights Manitoba and Ontario, which employ the largest portion of Canadian PAs.


Find Conference Board research at www.e-library.ca. 2

This series illustrates the role and impact physician assistants have in various health care settings, including funding attributes in jurisdictions where significant numbers work. In this report, funding refers to money provided by governments or organizations to pay for PA-related salaries (including wages and other compensation) and services.

The first report provided context by analyzing the role and impact of PAs

in health care. The second report calculated potential economic benefits

that hiring more PAs could generate for Canada’s health system. This

third installment provides an overview of the various funding sources

and considerations for the Canadian context. The purpose is to provide

evidence to engage in dialogue about the expansion of PA roles within

Canadian health care systems.

The PA profession began in the mid-1960s with military medics acting

as medical assistants.1 Today in Canada, one military and three civilian

PA education programs (two in Ontario and one in Manitoba) train

students in the medical model, typically over a two-year period.2

in Canada, PAs are employed in a variety of settings, from primary

to acute care academic centres. (See Table 1.) As of july 2017, CAPA

had 587 practising members.3 (See Table 2.) According to CAPA’s 2017

census data, 81.32 per cent are employed as civilian PAs, 16.48 per

cent are employed as CAf PAs (active duty), and 2.2 per cent are

contracted to the military.4 Most PAs work in hospital (38 per cent), family

practice (30 per cent), and military (17 per cent) settings.5 in terms of PA

certification, the highest number are found in Ontario (64.74 per cent)

and Manitoba (13.8 per cent) where PA university programs are housed.6

1 Mertens and Descoteaux, “The Evolution of PAs in the Canadian Armed forces.”

2 Vanstone, Boesveld, and Burrows, “introducing Physician Assistants to Ontario.”


4 ibid.

5 ibid.

6 ibid.

Chapter 1 | The Conference Board of Canada


Table 1Primary PA Work Setting (n = 267)

Practice setting Per cent

family practice 29.95

Canadian Armed forces 17.23

Hospital medicine 14.61

Hospital surgery 13.86

Emergency or urgent care 10.49

Out-of-hospital medical specialty 7.49

industrial/occupational/contracted coverage 4.12

Out-of-hospital medical surgery 2.25

Source: CAPA.

Table 2PA Employment by Province (n = 587)

Province Number

Ontario 380

Manitoba 81

nova Scotia 34

Alberta 32

British Columbia 23

Quebec 23

new Brunswick 8

newfoundland and Labador 1

Prince Edward island 1

Saskatchewan 1

northwest Territories 1

Other (Dublin and the U.S.) 2

Source: CAPA.

The first report on the value of PAs showed that their scope of practice

depends directly on the relationship with the physician. This is achieved

either through regulation (e.g., in Manitoba and new Brunswick) or

through individual medical directives (e.g., in Ontario, see “Medical

Directives”) that can vary widely across practice settings.7 in turn,

that relationship is reflected in the PA’s education, experience, and

competencies. CAPA serves as the foundation for CanMEDS-PA

(the Canada’s national Competency Profile for PAs—developed by

CAPA in conjunction with the Royal College and the College of family

7 Grimes and Prada, Value of Physician Assistants.



Physicians of Canada (CfPC) with input from the various programs.

its 2015 CanMEDS-PA competency profile outlines the PA’s role as

a physician extender.8 However, the individual relationship between

the supervising physician and the PA is determined by each PA’s

specific clinical role, scope of practice, and competencies.9 Experience,

education, and clinical setting are other determining factors.10

Medical Directives

PAs function under a set of medical directives that are designed to meet

the needs of patients and the skills of the individual PA as determined by the

primary supervising physician. These directives authorize the PA provider to

perform specific tasks for the patient population that the supervising physician

has instructed in the directive description, such as seeing patients rostered to a

supervising physician, taking histories and performing physical exams, ordering

diagnostic tests, leading a disease-centred clinic (e.g., a diabetes clinic), and

prescribing medications. Directives must explicitly outline every task within

a PA’s scope. The PA carries out physician orders when implementing the

medical directive.

As there are no legislated guidelines for medical directives, approval processes

can be individualized to each hospital and clinic. Generally, a directive must be

specific to a patient population and accepted by the physician’s or physicians’

supervising PA. in family medicine with 1 or 2 physicians, an agreement on the

required tasks can be implemented quickly. Emergency Department directives

could require agreement from 20 or more physicians. The supervision can either

be direct, in-clinic, or indirect, off-site, as long as the physician can be reached

by the PA.

Source: The Conference Board of Canada.

The second report calculated the economic benefits that could be

generated for the health system by hiring more PAs. Three areas of

economic modelling included primary care, emergency care services,

8 Canadian Association of Physician Assistants, CanMEDS-PA.

9 ibid.

10 Health Professions Regulatory Advisory Council, Literature Review on Physician Assistants: A Literature Review.



and orthopedics. They revealed that demand is growing twice as fast

as population growth, which strains the health system. integrating more

PAs into health care teams can help alleviate demand increases, reduce

wait times, and offset health workforce shortages.11 in primary care,

cost savings occur when PAs can substitute for 29 per cent or more of

a physician’s time. Adding PAs to orthopedic and emergency room care

would also generate savings when PAs substitute for specialists’ time.12

The costs and cost savings to the overall health care system calculated

in this report are considered at a system level, which does not reflect

the current reality in Canada. The existence of various provincial funding

envelopes is a central reason why long-term, sustainable funding for

PAs has yet to be established. Physician remuneration and oversight

comes from a separate budget than funding for hospitals or other

health professionals.

This report explores attributes of the funding mechanisms in jurisdictions

(both national and international) where PAs work. it is third in the

series and comprises a literature review and analysis of PA funding

mechanisms in four nations: the U.S., the U.K., the netherlands, and

Canada (Manitoba and Ontario). it provides an overview of the various

funding sources used to integrate PAs into health care streams and

provider remuneration mechanisms. Considerations are tailored to the

Canadian context in line with current health care reform directions.

Terminology: Task Transfer

Task transfer (also known as “physician delegation,” “task shifting,” and other

terms) is at the heart of physician extension, organizational research, human

resources theory, team-based care, reimbursement, distribution of responsibility,

quality of care, outcomes research, and labour economics. The term is

increasingly used to illustrate how PAs and nurse practitioners can be leveraged

to improve efficiency in the health care system.13

Source: Sewell.

11 Desormeaux and others, Gaining Efficiency.

12 ibid.

13 Sewell, “Task Transfer.”



Overview of Research Approach

This report presents four examples where funding supports successful

PA integration into respective health systems. (See Chapter 3.)

These examples were selected based on evidence from the literature

review and consultation with the advisory committee. Key informant

interviews with PAs, educators, association representatives, regulators,

workforce development specialists, and consultants (held between

May and September 2016) were conducted to inform the examples.

Each informant was selected based on knowledge and experience

integrating PAs in a health system and the impacts of their integration.

A standardized interview guide for the 45-minute telephone interviews

centred on the advantages and disadvantages of the funding models.

(See Appendix A for the key informant interview list and guide for

case examples.) Data collected also included program documentation,

formal evaluations, articles, and follow-up e-mail communications for

clarification and additional information.

Ontario is the province that employs the greatest number of PAs in

Canada. To gain insight into the challenges and opportunities that

characterize the funding experience, the Conference Board decided to

conduct nine additional key informant consultations with Ontario PAs

from a variety of settings, as well as those having direct experience

with the funding of PAs (e.g., supervising physicians).14 interviewees

were chosen from primary care, emergency medicine, endocrinology,

and orthopedic surgery settings. in some cases, their experiences

speak to the broader issues PAs in other jurisdictions are also facing.

Supplementary data were provided in the form of written questionnaires

and funding documents, hospital remuneration agreements, and

applications for government funding.

14 for confidentiality purposes, the names of these key informants are not included in this report.

Ontario is the province that employs the greatest number of PAs in Canada.


CHAPTER 2

Health Service Provider Funding Sources

Chapter Summary

• Aging is a key cost driver, with the highest health spending on seniors. Demand is growing at twice the population growth rate.

• internationally, Canada is still a high spender on health, and better efficiencies are needed.

• funding for PAs is derived from several sources, including provincial governments through demonstration projects, career start programs, and specific clinical services funding in primary care and hospital settings. Other sources include block funding (such as through academic speciality groups), or by direct funding from physicians or institutions.

• Remuneration or payment mechanisms for health providers vary and include annual salary, fee-for-service, capitation, and blended/mixed payment. in Canada, almost 76 per cent of PAs are remunerated via salary.



This chapter addresses the economic realities facing the Canadian health system. Funding sources for the delivery of care and remuneration or payment mechanisms for providers is included.

Canada’s health system faces significant pressures to become more

efficient and control costs. in 2016, health consumed 11.1 per cent of

GDP, or $228.1 billion.1 Overall health-spending growth is not keeping

up with the combined growth in inflation and population. in the last five

years, health spending decreased 0.6 per cent per year, mainly due

to downturns in economic growth and resulting government focus on

deficit reductions.2 Aging is a key cost driver, with the highest health

spending going to seniors. Chronic disease continues to rise due to

improved treatment but also with increased demand for access to care.

The second report in this series shows demand for physician services

growing at twice the pace of population growth, putting considerable

strain on the system and funding resources. Physician services spending

as a share of total health care spending has increased since 2005.3

in 2014, it accounted for 15.3 per cent, which is comparable to levels

seen in the late 1980s.4 The Canadian institute for Health information

(CiHi) reports slower growth in the largest spending areas, although

spending continues to grow for hospitals (29.5 per cent), drugs (16 per

cent), and physician services (15.3 per cent). in total, these three areas

account for 60 per cent of health dollars.5

internationally, Canada continues to be a high health care spender.

CiHi’s 2016 report of the 35 OECD countries (in 2014) identifies Canada

in the top per capita spenders, at C$5,543 per person (the U.S. remains

the highest at C$11,126).6 Spending in the U.K. is C$4,896 and in the

netherlands C$6,505.7 in 2016, CiHi projected overall total health

1 Canadian institute for Health information, National Health Expenditure Trends.

2 ibid.

3 ibid.

4 ibid.

5 ibid.

6 ibid.

7 ibid.



expenditure to reach $228.1 billion, or $6,299 per Canadian (11.1 per

cent of Canada’s GDP), compared with the OECD average of $4,463

(9 per cent of GDP).8

The health workforce implications of these economic realities are

significant. Canada ranks third in the world in the average number of

physician visits per capita, ahead of the other case countries.9 in 2015,

Canada’s physician density per 1,000 population was 2.2810 compared

with the OECD average of 3.3.11 in the past nine years in Canada,

the number of physicians and physicians per population has steadily

increased and is expected to continue for the next several years.12

interprofessional and collaborative care teams can help meet heightened

demand for services, help control costs, and reduce wait times. PAs

are employed in a wide variety of settings across the care continuum,

both within Canada and internationally. Since the turn of the century,

PA expansion has been widespread. However, barriers to PA integration

remain—with one of the most significant being a stable source of funding

and remuneration. This report will consider civilian funding models only.

Canada’s decentralized financing and delivery of health care services

results in significant variation in funding for PAs. Canadian funding for

PAs is derived from provincial governments (initially through pilot and

demonstration projects in Alberta and Ontario,13 career start programs,

and targeted clinical services funding), block funding14 (such as through

academic specialty groups), direct funding from physicians and

institutions (e.g., hospitals), and health delivery structures (e.g., Alberta’s

primary care networks and regional health authorities).15

8 ibid.

9 Canadian Medical Association, Physicians per 100,000 Population.

10 ibid.

11 OECD, Health at a Glance 2015.

12 Canadian institute for Health information, Physicians in Canada, 2015.

13 Although Ontario’s last demonstration project started in 2010 and finished in 2012.

14 CiHi notes that “The majority of APPs [alternative physician programs] funding emergency department, neonatal intensive care units, pediatric and gynecological oncology physician services receive block funding. The block funding is paid to a physician group or association, which is required to set up an internal governance structure that outlines how the physicians will be paid for the services negotiated under the APP contract,” Canadian institute for Health information, Physicians in Canada: The Status of Alternative Payment Programs, 2005–2006, 23. Some places allocate some of this funding to support other things, such as PA salaries.

15 jones and St-Pierre, “Physician Assistants in Canada.”

Barriers to PA integration remain—with one of the most significant being a stable source of funding and remuneration.



Each province has its own unique funding approach, especially with

models including PAs on family Health Teams (fHTs), Community

Health Centres (CHCs), Primary Care networks, and Primary

Care Teams.

Health care providers in Canada are paid in a variety of ways:

• annual salary

• fee-for-service payment—services provided and billed to the payer either

before or after the services are provided. (See “fee-for-Service Models.”)

• capitation—a prospective payment, typically for physicians who are paid

a fixed amount for each patient enrolled/attached to their practice, which

is often adjusted for risk, age, and sex

• blended/mixed payment—a combination of the previous or other

remuneration approaches

Fee-for-Service Models

funding PAs through fee-for-service (ffS) does not occur in Canada. ffS

models have their advantages and disadvantages.16 for physicians, they can

facilitate entrepreneurship and greater productivity; however, they also offer

disincentives to collaborative practices and instead encourage volume and

potentially unnecessary care or over-provision of services. Growing evidence

also shows that although capitation may support more collaborative care, it may

also encourage under-provision of care and unmet patient needs—or “cherry-

picking” (with providers selecting only healthy patients who are less likely to

seek care) as providers who are contracted by a health organization to provide

defined services may therefore want to keep their cost-per-patient low.17

An ffS model could work for PAs if the physician were permitted to bill

the government up to a maximum (e.g., a physician billing the government

$300,000 per year could bill an additional $130,000 per year for a total of

$430,000. This would allow the physician to pay the PA $100,000 and take a

supervisory stipend of $30,000). Potential advantages could include improved

patient care and productivity, and the physician would not have to pay out of

pocket. in this scenario, the government could save money because the PA

16 Goldfarb, Family Doctor Incentives.

17 Tholl and Grimes, Pathways to Better Primary Health Care for All Albertans.



salary is less expensive than paying an additional physician for similar work.

However, many legislators are hesitant to introduce additional ffS models as

they are less predictable than salaries, which can be controlled as costs rise.

in Ontario, doctors can bill only the Ontario Health insurance Plan (OHiP) for

work performed by a PA that counts as a quality interaction. They can bill OHiP

without seeing the patient if the PA performs a procedure that is included in the

OHiP General Preamble as a listed allowable delegated procedure. PAs are

permitted to practise without direct supervision.

Although ffS or blended models could enable data-gathering, the generation

of comparators, and more concrete measures of impact, quality, and workload,

existing limitations have generated little appetite in Canada for new ffS models

for other health care providers. Many legislators find remuneration through

salaries more palpable. As many models that are not pure ffS also require

“shadow billing” to capture the work done, ffS may not necessarily be better

than capitation. Careful consideration must therefore be undertaken in evaluating

the transferability of existing funding model to PAs.

Sources: Goldfarb; Tholl and Grimes; CAPA 2017 census data.

in Canada, most PAs are remunerated via salary (75.91 per cent),18

with civilian salaries ranging from approximately $75,000 (or less)

to $120,000 (or more) annually,19 depending on the individual

PA’s education, experience, scope of practice, and hours worked.

Military PAs20 are paid an average of $85,000 to $95,000.21 in 2017,

PAs became commissioned officers within the CAf.22 With this change,

the average salary range increases from $90,000 to 100,000+.23 Some

civilian PAs hold several part-time positions through contracts (including

teaching positions), which depend on the funding model being employed.

18 CAPA 2017 census data. The remaining 24.09 per cent is remunerated via hourly wage. CAPA’s data are based on a voluntary census in which 314 PAs participated.

19 Canadian Association of Physician Assistants, 2016 Annual President’s Report.

20 Canadian forces PAs work across the provinces and territories, respond to domestic disasters, have a long history of good service, return to civilian hospitals for more skill updates, and are well respected by nurses, doctors, and the public. When they transition from military to civilian PA roles in provinces like Ontario, they become unregulated. See Mertens and Descoteaux, “The Evolution of PAs in the Canadian Armed forces.”

21 Confidential e-mail communication.

22 Government of Canada, Canadian Armed Forces Creates New Officer Occupation for Physician Assistants.




Of those who participated in CAPA’s 2017 census, 83.44 per cent were

employed full time, 6.37 per cent were employed part time, 9.55 per

cent were unemployed, and 0.64 per cent had retired. Of the 277 who

answered the question regarding simultaneous jobs, 76.17 per cent held

one job, 19.86 per cent held two jobs, 3.61 per cent held three jobs, and

0.36 per cent held four or more jobs.24

Salaries provide several advantages, such as providing a stable source

of income, allowing PAs to be involved in non-clinical activities, and

encouraging collaborative care. However, studies of other health provider

groups show that salaries can also sometimes reduce productivity.25

Different funding sources for PAs are explored in greater detail in

the subsequent chapter.


25 Wranik and Durier-Copp, “Physician Remuneration Methods for family Physicians in Canada.”

Studies of other health provider groups show that salaries can also sometimes reduce productivity.


CHAPTER 3

Funding Models for Physician Assistant Integration

Chapter Summary

• Remuneration from U.S. federal medical programs for PA services is typically made through an ffS model (at 85 per cent of the physician’s fee schedule).

• The U.K. has a centralized PA primary care policy that is integrated to meet local needs and workforce gaps through health authorities.

• The netherlands has a statutory health insurance system with universally mandated private insurance. it encourages task transfer between physicians and PAs and has changed its tax system to increase PA integration.

• Manitoba employs a centralized process to allocate PAs across the province and is shifting PA funding to physician groups. Ontario provides PA funding support through education, Career Start, and a variety of clinical services funding.



This chapter focuses on four case examples that examine the sources of funding for PAs working in Canada and internationally. The U.S., the U.K., and the Netherlands were selected as good examples of comprehensive and homogenous funding models. For Canada, Manitoba was selected because it has the most experience with PAs and Ontario was included because it employs the most Canadian PAs.

The United States

Health System Overviewin 2016, U.S. per capita health expenditures reached $9,892 or

17.2 per cent of GDP.1 The Patient Protection and Affordable Care

Act, 20102 (often referred to as ACA) created shared responsibility

for health insurance between government, employers, and individuals.

it established 10 essential health benefit categories (e.g., hospital

services, mental health, maternal and child), with the range of services

being determined by each state.3 As a result, over a five-year period,

the uninsured rate fell from 16.0 to 9.1 per cent in 2015.4 The Act also

recognizes PAs as one of three primary care providers, along with nPs

and physicians. it allows PAs to lead patient-centred medical teams.

The Commonwealth fund (a private U.S. foundation whose stated

purpose is to “promote a high-performing health care system that

achieves better access, improved quality, and greater efficiency,

particularly for society’s most vulnerable”5) reported that health coverage

remains fragmented, with uninsured rates varying across the U.S.

population of 316 million, within a combination of private (48 per cent

1 OECD, OECD, Health Statistics 2017.

2 Patient Protection and Affordable Care Act, 2010.

3 The Commonwealth fund, 2015 International Profiles of Health Systems.

4 Obama, “United States Health Care Reform.”

5 The Commonwealth fund, Mission Statement.



of total health spending), public (33 per cent), or a mixture of sources.6

in 2014, the private insurance marketplace, regulated at the state level,

was created to give more access through income-based premium

subsidies for low- and middle-income people. Medicare (seniors and

disability care) and Medicaid (low income) are the public programs

mostly funded through tax revenue.

in 2014 (the nearest comparable year), both the U.S. and Canada had

2.6 physicians per 1,000 population.7 in 2011, the U.S. had four doctor

consultations per capita.8 One-third of U.S. physicians were in primary

care, in small self or group practices (usually 5 fTE physicians or

fewer).9 U.S. physicians are mostly ffS, although some fall under

capitation in private plans.

Experience With PAsThe U.S. is the world leader in integrating PAs into its health system.

Each of the 50 states regulates the practice of PAs, and decides who

is licensed to practise under a physician. As of 2017, 55 of 56 legislative

jurisdictions10 authorize PAs to practise with physicians in medical teams,

regulate PA scope of practice (which includes a wide range of treatment

and medical diagnostic activities, as well as prescribing), and are

reimbursed for their services.11

The American Academy of Physician Assistants stipulates that PA

practice laws include licensure as the regulatory term, full prescriptive

authority, scope of practice determined at the practice level, adaptable

collaboration requirements, co-signature requirements determined at

the practice level, and the number of PAs a physician may supervise

determined at the practice level.12 All but four states do not require

PAs to be supervised under the same roof as a physician; however,

a physician must provide supervision (oversee the activities of


7 OECD, OECD Health Health Statistics 2017.

8 ibid.


10 All 50 states, plus the District of Columbia and all U.S. territories except Puerto Rico.


12 American Academy of Physician Assistants, The Six Key Elements of a Modern PA Practice Act.



and accept responsibility for PA services) and be accessible via a

telecommunication device.13 for PAs employed in the federal government

(e.g., the U.S. Public Health Service, Department of Defense,

Department of Veterans Affairs), physician supervision is not required.

Every year, many states improve legislative wording surrounding

prescribing narcotics, attending births, etc.14 The scope of practice

across the states is far more similar than different.15

As of 2015, clinically active PAs and nPs comprise 20 per cent

of the U.S. health workforce,16 with low attrition rates and high job

satisfaction.17,18 As of 2017, labour market analyses indicate shortages

and high demand for both PAs and nPs,19 with demand for PAs

increasing over 300 per cent from 2011 to 2014.20 Data show that

230 accredited PA education programs train PAs and by 2020, all

programs must offer a graduate degree or risk losing accreditation.21

PA education programs average 27 months in length and include

2,000 clinical rotation hours. The Accreditation Review Commission

on Education for the Physician Assistant establishes U.S. education

standards. Graduating PAs write the national Commission on

Certification of PAs examination.

At the end of 2016, 115,547 certified PAs were practising in a wide

range of medical specialities, representing 44.4 per cent growth in

the profession over a six-year period.22 The 2016 annual report of the

national Commission on Certification of Physician Assistants found

that PAs were primarily employed in family medicine/general practice

(20.6 per cent), surgical subspecialties (18.5 per cent), and emergency


14 Key informant interview.


16 isolated PA data not available from this source.

17 Hooker, Brock, and Cook, “Characteristics of nurse Practitioners and Physician Assistants.”

18 Hooker, Kuilman, and Everett, “Physician Assistant job Satisfaction”; Hooker, Brock, and Cook, “Characteristics of nurse Practitioners and Physician Assistants.”


20 American Academy of Physician Assistants, What Is a PA?

21 Accreditation Review Commission on Education for the Physician Assistant, Accreditation.

22 national Commission on Certification of Physician Assistants, 2016 Statistical Profile of Certified Physician Assistants.

At the end of 2016, 115,547 certified PAs were prac-tising in a wide range of medical specialities.



medicine (13.2 per cent).23 U.S. PAs perform a wide variety of roles

and practise in 16 different settings, including primary care, hospitals,

CHCs, mental health facilities, and more.24 The top two PA practice

settings are office-based private practice (42.2 per cent) and hospitals

(38.9 per cent).25

in 1974, Kaiser Permanente northwest was the first to integrate PAs

into a team-based setting. According to the Patient Protection and

Affordable Care Act, 2010, public health insurance employs PAs to

improve access and quality of care. The survey was conducted by

the Veteran Health Administration (VHA) of PAs and nPs in 118 acute

care hospitals and revealed similar caseloads, scopes of practice, and

patient–nurse manager satisfaction levels.26 The first Conference Board

PA report also cited several U.S. impact studies. A retrospective 2015

study on collaborative cardiovascular care delivery models revealed

that combining physicians with other advanced practice providers

(PAs and nPs) could deliver overall outpatient care quality comparable

with physician-only models.27 A 2016 U.S. study showed similar results

in primary care.28 numerous systematic reviews and other studies

support this finding, including community practice and rural region

geriatrics.29,30,31 Another VHA study found that PA productivity was

higher in primary care roles than in other specialty areas, but also in

rural or non-teaching settings and where their scope of practice allowed

significant autonomy.32 Yet another VHA study found that employing

PAs in orthopedic settings increased patient volumes by 31 per cent,

and over a one-year period, five PAs were able to manage 28 per cent

23 ibid.


25 ibid.

26 Kartha and others, “nurse Practitioner and Physician Assistant Scope of Practice in 118 Acute Care Hospitals.”

27 Virani and others, “Provider Type and Quality of Outpatient Cardiovascular Disease Care.”

28 Mafi and Landon, “Comparing Use of Low-Value Health Care Services.”

29 Lichtenstein and others, “Effect of Physician Delegation to Other Healthcare Providers.”

30 Henry, Hooker, and Yates, “The Role of Physician Assistants in Rural Health Care.”

31 Halter and others, “The Contribution of Physician Assistants in Primary Care.”

32 Moran and others, “factors Associated With Physician Assistant and nurse Practitioner Productivity.”

A VHA study found that employing PAs in orthopedic settings increased patient volumes by 31 per cent.



of total orthopedic encounters.33 Research into the optimal use and

role delineation of physicians, PAs, and nPs in a variety of settings

is ongoing.34

Funding SourcesOver the last decade, the U.S has increasingly adopted delivery

models such as the patient-centred medical home (with a focus on

care continuity and coordination) and accountable care organizations

(a network of providers contracted to provide care to a defined population

with quality targets). Thus, the health care payment system has also

shifted, with 30 per cent of traditional Medicare payments (the federal

health insurance entitlement for the elderly) now going through

alternative payment models such as bundled payments (i.e., a single

payment for all services relating to an episode of care delivered by

multiple providers) or accountable care organizations.35 With this shift

comes the need to better determine cost-effectiveness of these new

delivery models. A national survey of family medicine practices showed

that PA productivity (defined as mean annual patient encounters)

exceeds that of nPs and physicians in physician-owned practices, as

well as nPs in hospital or integrated delivery system-owned practices.36

Data supporting PAs and nPs as productive members of primary care

teams have led some to advocate for more research, especially in rural

and underserved communities, where physician-owned practices are

more common.

Practices, hospitals, and PAs are reimbursed for the work PAs do

through billing numbers. Between 2000 and 2013, PA wages increased

by 40 per cent (compared with the cumulative 35.3 per cent inflation

rate).37 in 2016, the average certified PA salary was US$104,131, with

pathology, dermatology, emergency medicine, critical care medicine,

33 Reed and Hooker, “PAs in Orthopedics in the VHA’s Community-Based Outpatient Clinics.”

34 Morgan and others, “factors Associated With Having a Physician, nurse Practitioner, or Physician Assistant”; Dehn, Everett, and Hooker, “Research on the PA Profession: The Medical Model Shifts”; Timmons, “The Effects of Expanded nurse Practitioner and Physician Assistant Scope of Practice.”


36 Essary, Green, and Gans, “Compensation and Production in family Medicine.”

37 Quella, Brock, and Hooker, “Physician Assistant Wages and Employment.”



and surgery subspecialties paying the most.38 Within the care delivery

models, physicians are not remunerated every time a PA sees a patient.

for example, in Washington state, PAs may be out in a rural area

seeing patients, but billing for their services takes place centrally within

a physician’s office or the hospital that owns the clinic. if a PA sees a

federally insured (e.g., Medicare or Medicaid) patient without a physician

supervisor (such as in a rural setting), compensation is provided at

85 per cent of the visit. Reimbursement rates are higher if the physician

is on-site and sees the patient along with the PA. These billing fees go

to the physician or hospital corporation, from which the PA salary is then

paid. As a result, in family medicine, PAs may return insurance revenue

of 2.5 times their salary.39 in this scenario, PAs are allowed to bill, but

the physician or corporation is actually doing the billing, so PAs are not

sole entrepreneurs. Remuneration from public payers (i.e., Medicare or

Medicaid) for PA services is typically provided through an ffS model, at

85 per cent of the physician’s fee schedule (using the same billing code).

nearly all private payers cover PA services at a similar rate.40

A 2017 study revealed that approximately 13.5 per cent of certified U.S.

PAs worked in two or more clinical positions. Of these, 44 per cent did

so to supplement earnings from their principal clinical position, 26.5 per

cent did so because they enjoyed working in a variety of clinical settings,

18.1 per cent did so to gain experience in a different aspect of clinical

care, 2.1 per cent did so because they were not offered full-time work in

their principal clinical position, and 9.3 per cent did so for other reasons.41

Revenues generated by PAs in rural settings can create employment

opportunities, wages, salaries, and benefits for staff, which in turn

are circulated throughout the local economy. Eilrich developed an

input-output model to estimate the direct and secondary effects of a

rural primary care PA or nP on the community and surrounding area.

Through the modelling of two scenarios, we see that a rural PA or nP

can have an employment effect of 4.4 local jobs and labour income



40 American Academy of Physician Assistants, Third-Party Reimbursement for PAs.

41 jeffery and others, “Physician Assistant Dual Employment.”

Revenues gen-erated by PAs in rural settings can create employ-ment opportunities, wages, salaries, and benefits for staff.



of $280,476 from the clinic. if a community has a hospital, the total

employment effect increases to 18.5 local jobs and $940,892 of labour

income.42 Another recent study in Washington State showed that 18 of

the 39 rural hospitals now staff their emergency departments with PAs

and nPs.43

Considerations for Canadian jurisdictions based on the U.S. experience

include exploring different funding models to employ PAs based

on setting (i.e., primary or secondary care) and source of funding

(i.e., private or public payer), leveraging cost-effectiveness results of

new team-based primary care models to determine which provide the

best value for money and quality, employing a critical mass of PAs to

facilitate wider acceptance and knowledge of the PA role, enhancing

the value of PAs by employing them in more rural/remote and indigenous

settings, regulating PAs to allow them to work as autonomous providers,

remunerating PAs through a salary model, and financing the funding for

PA services from public payers through a discounted ffS model.

The United Kingdom

Health System OverviewThe English nHS centrally oversees England’s health system, with

the Department of Health overseeing stewardship of this universal

health system for 64 million people. nHS England manages the budget,

209 local Clinical Commission Groups, and ensures that mandate goals

are met.44 Local government authorities manage public health spending

by establishing health and well-being boards. England is divided into

13 local areas and each area is given flexibility for its local budget,

although it must meet centrally determined objectives. in 2016, U.K.

health spending per capita was $4,192, or 9.7 per cent of GDP, with

approximately 84 per cent financed through public sources (general

taxation and a payroll tax).45

42 Eilrich, “The Economic Effect of a Physician Assistant or nurse Practitioner in Rural America.”

43 nelson and Hooker, “Physician Assistants and nurse Practitioners in Rural Washington Emergency Departments.”


45 OECD, OECD Health Statistics 2017.



The number of physicians in the U.K. increased by over 50 per

cent between 2000 and 2012, and reached 2.8 physicians per

1,000 population in 2016.46 This is due to a rise in the number of

graduates from programs within the U.K. to reduce its reliance on

foreign-trained physicians. Like Canada, primary care physicians act

as gatekeepers to secondary care,47 with two-thirds acting as private

contractors. Payment is a mixture of capitation for essential services

(60 per cent) and ffS for additional services, such as vaccines. Some

pay-for-performance occurs for chronic illness care coordination and

evidence-based clinical interventions.48 There has been an increase in

the number of general practitioners (GPs) being employed as locums,

now at 20 per cent.

Experience With PAsin the U.K., PAs (called physician associates49) are relatively new nHS

care providers. in 2003, the U.K. embarked on its first use of PAs

imported from the U.S. to augment primary care practices in West

Midlands.50 By 2016, the U.K. had 288 PAs and up to 577 students.51

PAs, along with other Advanced Clinical Practitioners, have been

introduced to combat shortages in primary and secondary care—

especially urgent, acute, and emergency care areas. A 2015 nHS

primary care study confirmed that PAs can successfully manage

a portion of physician clinical workloads. in this case, same-day

appointments showed similar outcomes and processes at a lower cost.52

PAs are not currently regulated, but nHS Health Education England

(HEE),53 nHS England, and workforce leads from Scotland (nHS

Grampian), northern ireland, and Wales are working collaboratively

46 ibid.

47 Secondary care is medical care provided by a specialist or facility upon referral by a primary care physician.


49 in 2013, physician assistants were renamed physician associates because of nHS salary banding.


51 Ritsema, Faculty of Physician Associates Census Results 2016.

52 Drennan and others, “Physician Associates and GPs in Primary Care.”

53 HEE is an executive non-departmental public body of the Department of Health, which provides coordination and national leadership for the public health workforce’s education and training in England.



with the Department of Health, General Medical Council, the Royal

College of Physicians faculty of Physician Associates, and key national

stakeholders to progress discussions around statutory registration and

an aligned approach toward funding the cost of PA education.54 Many

U.K. doctors feel that current legal limitations are hindering their ability

to use PAs to their full potential and “strongly support statutory regulation

for PAs as a necessary component for the most effective use of these

practitioners within the nHS.”55

With interest in PA recruitment growing and increasing workforce

challenges in general practice, the U.K. government’s intention is

to develop 1,000 primary care-based physician associates by 2020, to

support GPs in their work.56 However, in 2016 only around 20 per cent

of PAs had been recruited into or were working within primary care.57

By the end of 2016, the U.K. had about 30 programs for physician

associates.58 Based on 2016 enrolment numbers, an estimated

3,200 PAs will have graduated by 2020. To meet the government’s

20 per cent target, recruitment of PAs into primary care must increase

by 57 per cent.59 PAs in England are required to recertify every six years.

This demonstrates that they have maintained their generalist medical

knowledge and can safely change jobs whenever they wish. As one U.K.

PA educator notes, alumni do switch fields. Although some program

graduates still work in their original post-graduation post, many move

specialties as personal, population, or nHS needs change (which is also

common in the U.S.).60

The PA profession requires an undergraduate qualification, but not

necessarily previous clinical training. PA training is split (approximately)

50/50 between theory and clinical practice and is based on the

curriculum as specified in the national PA Competence and Curriculum

framework (CCf). The CCf defines the range of academic knowledge


55 Williams and Ritsema, “Satisfaction of Doctors With the Role of Physician Associates,” 116.




59 Health Education England, Proposal.


PAs in England are required to recertify every six years.



and clinical experience expected of graduating PAs, which includes a

minimum of 1,600 hours of practice placement time, across seven clinical

areas, with additional time spent in clinical skills simulation training and

300 hours devoted to additional clinical training, which is typically aligned

to local workforce needs.61

The average tuition fee for PA programs is £18,000 (C$32,426)62

for two years. HEE is committed to investing in the growth of the

PA workforce. Different approaches and models of investment have

been applied across HEE local areas in recent years to facilitate this.

PAs graduate with either a master’s degree or post-graduate diploma

(depending on the university), and must complete a national certification

exam. The recent supply of new graduates from PA programs was

estimated at 89 in 2014, 232 in 2015, and 827 in 2016.63 in 2017, over

1,000 students are enrolled.64

PAs in the U.K. work in a wide range of specialist areas in over

35 different U.K. nHS acute hospital trusts and approximately 35 primary

care settings.65 Most hospital PAs work in general adult medicine, with

surgical specialities (mainly trauma and orthopedics) accounting for

20 per cent. Approximately 20 per cent also work in general practice

where they conduct face-to-face urgent and non-urgent consultations,

review test results, and provide chronic disease management services.66

in contrast to the U.S. and Canada, there is currently no U.K. military

PA role and no defined pathway for veteran medics to enter civilian

PA programs.67

Funding SourcesHEE’s collective aim is to agree to a single investment model that

addresses both local needs and the national imperative to increase the

PA workforce in primary care. The proposed plan looks to incentivize

61 Department of Health, The Competence and Curriculum Framework for Physician Assistants.

62 OECD, Purchasing Power Parities.


64 ibid.

65 Parle and Ennis, “Physician Associates.”

66 ibid.




PA recruitment in primary care by allowing local teams to target

investments based on local priorities. investment and incentivizing

options under consideration include:68

• Training Support Allowance—to offset student training costs, such as

tuition fees and clinical placements to course providers (with a suggested

amount of £6,500 or C$11,70969);

• Primary Care Placement Support—to support placement providers for

student-mandated placement time of 180 hours in clinical practice (with

a suggested amount of £700 or C$1,26170);

• Secondary Care Placement Support—like primary care but for

secondary care placements (with a suggested amount of £3,175

or C$5,71971).

Another intriguing PA investment option discussed in the HEE proposal

is the idea of a supervised clinical internship year for first-year

PA graduates.

As U.K. PAs are salaried, their compensation is not linked to the volume

or type of patients seen. nHS employers typically remunerate PAs in

the range of £33,000 to £42,000 per year (C$54,447 to C$75,660).72

The Agenda for Change is a national pay reform initiative for non-

medical staff which feeds into this work. A nationally standardized

approach73 does have its advantages as training funding does not

need to be found locally.

A key informant interview revealed communication to be a key ingredient

to garner PA support and integration. With increased support from

national stakeholders, the PA is increasingly finding a place in the

U.K. clinical workforce.74 With significant differences in the training

and clinical skills mix between the PA and Advanced Practice nurse

(APn) professions, the interviewee proposed that both professions

68 Health Education England, Proposal.

69 OECD, Purchasing Power Parities.

70 ibid.

71 ibid.

72 ibid.

73 Similar to the Manitoba provincial approach.




be viewed as collaborative and equally necessary parts of any future

urgent and acute workforce planning. The interviewee further contends

that both professions have an “equally important part to play in the

multi-professional clinical workforce of the future.”75

Acceptance of PAs in secondary care settings also appears to be

increasing. A 2016 study by the Royal College of Surgeons of England,

which looked at perceptions of training and the potential offered

through new team models, found that resistance had mostly dissipated

in hospitals using new team models incorporating PAs and APns.76

However, some primary care physicians still challenge their acceptance

as mandates and roles are less clear.

Considerations for Canadian jurisdictions based on the U.K. experience

include employing a funding model designed to address local needs

(specifically for primary care and emergency medicine), requiring

re-certification every few years, creating quality practice placements with

funding support, and employing an effective communications strategy

to inform stakeholders of PA roles as collaborative and complementary

providers of health care services who are part of a multidisciplinary

health care workforce and who can be better leveraged in the system

to efficiently and effectively address current and future workforce gaps.

The Netherlands

Health System OverviewThe Dutch health system is centrally run. The national government

determines and monitors health care priorities, legislation, and quality

for a population of almost 17 million. in 2016, health spending was

10.5 per cent of GDP, or $5,385 per capita.77 Health services are

provided through social health insurance (with a basic benefit package

financed from general taxation and a reallocation of payroll levies

among insurers through a community-based risk adjustment system)

75 ibid.

76 Limb, “Physician Assistants Can Lighten Doctors’ Workload.”




and a compulsory social health insurance system for long-term care.78

Seventy-eight per cent of curative services are publicly financed. All

residents must purchase statutory health insurance from private insurers

(primarily from four companies). insurers and contracted providers

engage in strategic purchasing.

Prevention and social support services are financed separately through

general taxation (which is not included in social health insurance).

in 2015, a national long-term care reform effort held municipalities and

health insurers responsible for most outpatient long-term services and

all youth care to allow needs at the local level to be better addressed.

in 2015, the netherlands had 3.5 physicians per 1,000 population, with

8.2 doctor consultations per capita.79 Medical specialities have risen

at differing rates, with overall growth at 32 per cent from 2005 to 2013.

nuclear medicine (a relatively newer speciality) is growing at 61 per

cent, whereas internal medicine grew only at 20 per cent in the same

time frame.80

Experience With PAsThe content in this section is exclusively informed by the key informant

interview conducted for the netherlands experience as many key

primary sources are available in Dutch only. There has been a

significant increase in the number of PAs in the netherlands over

the past decade (just 4 in 2011 to more than 1,000 in 2016) because

of an expected shortage of physicians.81 five PA education programs

produce 150 graduates per year. in the last decade, the annual intake

for training PAs and nPs has increased from 325 to 700, and is expected

to increase further.82,83



80 Capaciteitsorgaan, The 2013 Recommendations for Medical Specialist Training.


82 Van Vught and others, “implementation of the Physician Assistant in Dutch Health Care Organizations.”

83 isolated PA data not available in this source.



PAs work in all health care settings, from forensic to academic; however,

most are employed in hospitals, followed by primary care.84 To enter

a PA program, an individual must have already secured a position

in a hospital. After graduation, some PAs switch specialities. Eligible

students must have a bachelor’s-level degree in areas such as nursing

or physiotherapy, as PA education programs are master’s level plus

two years of clinical experience. PA training places individuals at the

same level as a resident. Most Dutch PAs require little guidance from

specialists.85 Under a work/education model, PAs are employed two days

per week under a supervising mentor physician (which helps ensure

a job upon graduation). Dutch PAs are not employed in the military.

Dutch legislation covers a multitude of subjects, including reimbursement

by insurance companies. PAs can bill insurance companies, as they are

considered independent health care providers. However, PAs always

work in collaboration with physicians. As indicated in the first report

in the PA series, few studies detail the collaborative relationships with

PAs. However, a 2015 Dutch study of PAs working in four different care

models showed that in hospital wards, direct and indirect patient care

differs. in PA-only models, PAs were able to provide the highest provider

continuity and spent more time on direct patient care. Another Dutch

cross-sectional study on general skill levels showed that physicians and

PA students achieved similar history-taking, physical examinations, and

communication scores. Most PAs are found within surgical specialities,

whereas nPs tend to be used more in psychiatric specialities, long-term

care, and nursing themes. in the netherlands, nPs act as an experienced

nurse, whereas PAs deliver medical care.86 Originally, acceptance among

medical specialists was low as they believed PAs were taking their

salaries. However, further studies now show that physician salaries have

not decreased with the introduction of PAs. Patient satisfaction with PAs

is comparable to that with physicians.87

84 Timmermans and others, “Physician Assistants in Medical Ward Care.”

85 Van der Biezen and others, “factors influencing Decision of General Practitioners and Managers.”

86 Van Vught and others, “Analysis of the Level of General Clinical Skills of Physician Assistant Students.”

87 Meijer and Kuilman, “Patient Satisfaction in the netherlands.”

Patient satisfaction with PAs is com-parable to that with physicians.



The Advisory Committee on Medical Manpower Planning

(“Capaciteitsorgaan” in Dutch) is a private organization that oversees

health workforce planning, including PAs. its mission is to advise the

Ministry of Health and stakeholders every two to three years on the

intake of medical graduates in post-graduate training programs for

medical specialities. The netherlands model includes vertical substitution

or task transfer of work to PAs and nPs.88 A recent study on the number

of PAs and nPs in the Dutch health system and their labour market

characteristics (such as hours worked, age, outflow, and more) has

been used to inform a conceptual model and has been disaggregated

to medical specializations.89 Study data show that PA employment

differs among medical specialities and regions. The largest increases

have been in general practice, gastroenterology, orthopedics, and

internal medicine. However, in relative terms, the ratio of PAs to GPs

is still low in general practice (0.7 fTEs per 100 fTE GPs) and higher

in neurosurgery and thoracic surgery.90

Funding Sourcesin terms of funding, insurance companies negotiate with boards of

hospitals for contracted services. A PA salary is lower, so if PAs can

deliver the same service as physicians, then the hospital saves money.

insurance companies do not assign set fees for PAs. However, this

is expected to change, with some insurance companies requesting

a special fee for PAs (such as .88 of a normal fee).91,92 Dutch PAs

receive a salary from the hospital. The hospital then invoices the

insurance company, which then pays the hospital. if care is of a high

standard, insurance companies are not particular about the type of

provider and PAs negotiate their own salaries. The Dutch Health Care

Authority (nederlandse Zorgautoriteit) determines most provider fees,

88 Ellen Dankers-de Mari (Capaciteitsorgaan), e-mail communication with Gabriela Prada and Kelly Grimes, September 13, 2016.

89 ibid. Report available only in Dutch.



92 if remuneration changes like this incentivize hospitals to hire PAs to take on physician tasks, PA acceptance among medical specialists may decline and tensions that do not exist within the current funding model could be introduced.



with an average salary of €80,000 (CAD$133,477).93 in 2012, self-

employed general practitioners (GPs) earned an average gross annual

income of €97,500 (CAD$175,641).94 Government representatives

have indicated that high GP salaries are incentivizing potential task

realignment. (See “Dutch GP funding.”)

Dutch GP Funding

Dutch primary care physicians are paid through a mix of capitation and ffE for

core activities (75 per cent in total). in 2015, the Dutch government began a new

GP funding model with three segments:95

• Primary care services (majority of spending) through a capitation fee per

registered patient, a GP consultation fee, and a consultation fee for ambulatory

mental health care at the GP practice. Most GPs employ nurses and

psychologists on salary with fees negotiated by the Dutch Health Care Authority.

• Program funding (15 per cent of spending) provides multidisciplinary care

for diabetes, asthma, and chronic obstructive pulmonary disease, as well as

for cardiovascular risk management. These fees are negotiated with insurers.

• Pay-for-performance and innovation (10 per cent of spending) are where GPs

and insurers negotiate additional contracts—including prices and volumes.

new GP funding models will impact the development of the PA profession as

hospital and insurance companies will look for ways in which PAs could be used

to lower costs under the new remuneration system.

Source: Capaciteitsorgaan.

Considerations for Canadian jurisdictions based on the netherlands’

experience include adopting national needs-based workforce planning

that emphasizes task transfer, implementing scenario-planning to advise

governments based on supply and demand, using strategic purchasing

93 OEDC, Purchasing Power Parities.

94 ibid.

95 Capaciteitsorgaan, The 2013 Recommendations for Medical Specialist Training.



with contracted providers based on local needs, and leveraging the

tax system to facilitate PA integration and task realignment for self-

employed physicians.

Manitoba

Health System OverviewManitoba’s Ministry of Health, Seniors, and Active Living funds health

care services provided at five regional health authorities to 1.3 million

people. it has additional centralized structures for CancerCare Manitoba

and Diagnostic Services Manitoba. The Centre for Healthcare innovation

ensures research and evidence are translated into improved patient

outcomes, enhanced patient experiences, and improved access. in 2016,

provincial health spending as a percentage of Manitoba’s budget was

forecast to reach 42 per cent, with per capita growth of 3.9 per cent or

$7,120 per person.96 Provincial priorities include capacity-building, health

system innovation, health system sustainability, improved access to care,

improved service delivery, and reduced health disparities that improve

the health of Manitobans. Manitoba’s primary care strategy develops

teams around the needs of communities served by the team, so each

is unique.97 The province recently adopted a provincial health leadership

initiative that links talent management with health reform.

Experience With PAsManitoba has the longest history of regulating PAs in Canada and

employs PAs in various models of care. CAPA’s 2017 census data

show that 13.8 per cent of certified PAs in Canada were employed

in Manitoba.98 They were regulated as clinical assistants (CAs)99 from

1999 to 2009 and since 2009, as PAs under The Medical Act.100

Manitoba and new Brunswick are the only Canadian jurisdictions


97 Bohm and others, “Experience With Physician Assistants in a Canadian Arthroplasty Program”; Bohm, Dunbar, and Bourne, “The Canadian joint Replacement Registry.”

98 Canadian Association of Physician Assistants, CAPA 2017 census data.

99 CAs are typically international Medical Graduates (iMGs) operating in a physician extender role.

100 The Medical Act.



that regulate this health provider group, although Alberta regulation

is expected in 2017–18 as PA inclusion under the Alberta Health

Professions Act101 received Royal Assent in the legislature in 2016.

in 2014, the 72 Manitoba PAs and CAs organized into one collective

bargaining unit.102 Both are used interchangeably, although routes for

education and hiring are different. in 2003, Manitoba first recruited

two PAs for cardiac and plastic surgery (one military-trained and the

other trained in the U.S.) on the recommendation of a physician who

had worked with PAs south of the border.

in 2008, the University of Manitoba established its first education

program, producing master’s-prepared PAs with admission requirements,

including a four-year bachelor’s degree. in 2016, it produced

12 graduates. However, demand is greater (approximately 25 positions)

than the number of graduates. Manitoba views PAs as a rapidly

expanding profession that is well accepted by physicians.103 in Canada,

11 per cent of PAs graduated from the University of Manitoba and almost

80 per cent of them are employed in Winnipeg.104 Practice settings now

include critical care, psychiatry, rehabilitation, and more. However, most

are employed in surgical, emergency, and primary care areas. in the

last few years, Manitoba PAs have also been working in community

and rural sites.

Since 2013, Manitoba family medicine physicians have employed PAs

in three practice model pilots (CHCs, ffS family practice, and hospital-

based family medicine), later adding three more sites.105 The pilot

showed early impacts to be most evident in two settings—hospital-based

family medicine placements (e.g., where they successfully improved

patient satisfaction, increased the number of unattached patients,

and facilitated admission and discharge) and over-panelled practices

(e.g., where physicians were well established and motivated to meet

101 Alberta Health Professions Act.

102 Winnipeg Regional Health Authority, Physicians and Clinical Assistant Collective Agreement.


104 ibid.

105 Bowen, Introduction of Physician Assistants Into Primary Care.

Since 2013, Manitoba family medicine physicians have employed PAs in three practice model pilots.



patient needs by changing practice patterns).106 However, the evaluation

noted that more strategies quantifying identified impacts, and identifying

impacts specifically attributable to the PA role, are required.107

Funding SourcesUntil 2015, Manitoba PAs were primarily employed by hospitals and other

organizations funded by government on a line-by-line basis to regional

health authorities to support PA salary payments. Under this PA funding

model, Manitoba centralized its PA allocation with the establishment of

a provincial director who worked with the Vice-President Medical at the

Winnipeg Regional Health Authority and the Assistant Deputy Minister

to decide which programs would receive a PA or CA. The province

funded PAs to work in primary care and within the regional health

authorities for medical specialty programs or emergency departments.

in some instances, academic specialty groups pay PA salaries from

within a program budget. Each program made a case for why a PA

was needed, as only 12 were funded.108 A matching process occurred

between provincial need and student interests.

With the 2016 change in government, Manitoba shifted PA funding and

remuneration from hospitals (or other organizations directly funded by

government) to physician groups (that also receive government funding

through billings). As funding was provided at the same level as the

previous year (no new PA funding was provided in the 2016 budget),

the provincial director worked with established programs to reallocate

government funding to support new PA positions within the existing

program budget for the 12 graduates of the 2016 cohort. interestingly,

program demand for PAs was seemingly unaffected by the lack of

new provincial funding, and demand has continued to outpace supply.

for example, one key informant indicated that while there were only

12 graduates to fill PA positions, he received approximately 25 proposals.

in this instance, PAs were placed in programs that could demonstrate

their ability to support a PA position by either redirecting existing

106 ibid.

107 ibid.

108 Manitoba Health, Request for Funding New PA Position Template.



program funds or recouping costs by way of physician shadow billing.

Programs that wanted a PA submitted proposals that not only met the

original evaluation criteria, but also demonstrated financial feasibility for

supporting the PA. in many cases, PA salary funding is now completely

supported by the physician group and is no longer dependent on

government funding.

As Manitoba PA salaries range from $75,000 to $110,000 per year,

it is important for programs requesting PAs to demonstrate their ability

to maintain approximately $100,000 per year to support a PA. in the

previous model, overtime and shift differential were covered but there

were no bonuses or pay-for-performance. it is unclear if or how similar

remuneration elements will be maintained in the absence of government

funding or whether physician groups will absorb this responsibility.

Before the government change, discussion was unfolding around the

sustainability of the previous funding model. The College of Physicians

and Surgeons of Manitoba regulates PAs working under supervising

physicians. ffS physicians in Manitoba and Ontario are not allowed

to charge for patients the PA sees without physician supervision.

Supervision may either be direct (e.g., visual observation of the PA

during clinical work) or indirect (e.g., direction and management of the

PA’s clinical work without direct, visual observation).109 Supervision levels

are negotiated between PAs and their supervising physicians on an

individual basis and are determined by the particular practice setting,

the PA’s experience, and the physician’s comfort level.110 The Health

Professions Regulatory Advisory Council (HPRAC) noted that although

“a general scope of practice may exist, each PA’s scope of practice is

unique and based on the supervisory relationship, level of autonomy

and delegation of various controlled acts.”111

Although funding has shifted from hospitals and other employers directly

funded by the government to physician groups, and additional funding

has not been added, the Manitoba government is supportive of PAs

because they have consistently demonstrated an ability to increase

109 The Ontario Physician Assistant initiative, Roles and Responsibilities of Supervising Physicians.

110 Health Professions Regulatory Advisory Council, The Health Profession Assistant.

111 ibid., 18.

in many cases, PA salary funding is now completely supported by the physician group and is no longer dependent on gov-ernment funding.



throughput (i.e., more patients seen, more procedures performed

annually), especially in areas where waiting lists are long. Dollars are

saved around the infrastructure costs, and physician time is also freed

up to undertake more complex tasks.112 A key informant cited a particular

clinic as an example, where the physician saw 65 patients and the PA

saw 30. This allowed the physician to perform additional tasks, such as

going to the operating room, seeing more patients, providing additional

education, etc.

Manitoba is considering a province-wide tracking system with a web-

based application based on iCD-10 codes (using Typhon Group’s PAST

Activity Tracking system) to log data on each patient encounter.113

This model has the additional advantage of more accurately tracking

the activities performed by PAs, which will support better planning,

forecasting, and research. Although identifying and adapting the best

funding models for PAs in Canada is challenging, PAs in primary care

are bringing important benefits, including improving access and care

quality, reducing waiting times, and improving the quality of physician

work life.

Manitoba’s province-wide tracking system will have an important role

in the establishment of a dedicated source of funds for PA employment,

as the tracking system will determine if creating subsidized PA billing

codes for specific tasks is feasible in a new model. The activity tracker

may illuminate whether a one-size-fits-all funding model will facilitate

or hinder the movement of PAs into the programs where they are most

needed. indeed, different care settings may necessitate unique funding

models, in which case PA funding models would vary depending on

the clinical setting. A key informant noted that, in many aspects, a shift

to employers funding PAs may help push the profession toward the

fundamental and systemic change that is needed to realize the full value

of PAs within the health care system. Experimentation and consideration

of methods and models from the U.S. and Ontario may play a significant

role in defining the future of PA funding in Manitoba.

112 Bohm, Dunbar, and Bourne, “The Canadian joint Replacement Registry”; Dies and others, “Physician Assistants Reduce Resident Workload and improve Care.”

113 Key informant interview; Typhoon Group, About Us.

Manitoba’s province-wide tracking system will have an import-ant role in the establishment of a dedicated source of funds for PA employment.



Some considerations for other Canadian jurisdictions based on the

Manitoba experience include adopting a centralized process to allocate

PAs across the province based on identified program and/or community

needs, enabling physicians to bill the funder an ffS for tasks undertaken

by a PA, but at a reduced rate that reflects the supervisory role assumed

by that physician, and installing province-wide tracking or monitoring

systems to provide an understanding of where and how PAs work and

their impact on patient outcomes and system efficiency.114

Ontario

Health System OverviewThe Ontario health care system is a complex network of various health

care organizations working together to meet the health care needs

of 13.9 million Ontarians.115 in 2016, provincial health spending as a

percentage of Ontario’s budget was forecast to reach 41 per cent, with

per capita growth of 1.1 per cent, or $6,144 per person.116 The Ministry

of Health and Long-Term Care (MOHLTC) acts as the organizing body

for the system. MOHLTC plays an integral role in setting the overall

direction and provincial priorities for the health system; developing

policies, legislation, regulation, and directives to support those

provincial priorities; monitoring the overall performance of the system;

and establishing levels of funding for the health system.117 formed in

2006, the 14 Local Health integration networks (LHins) are the local

administrative bodies for the system. They are responsible for health

care services planning and funding in their regions, including hospitals,

long-term care homes, Community Care Access Centres, community

support services, CHCs, and addictions and mental health services

under the Patients First Act 2016118 and could potentially play a role

in organizing PA positions. it is important to note that LHins are not

114 Tracking of PA work and contributions to patient health and to the health care system should be integrated into a larger health care workforce monitoring system.

115 Statistics Canada, Population by Year, by Province and Territory.


117 Health Care Tomorrow, Ontario Health Care System.

118 Government of Ontario, Ontario Passes Legislation.



responsible for the funding of physicians,119 public health, ambulance

services, or provincial networks. Also, as they are not involved in

mandating where physicians can work, PA positions would require

innovative means for physician supervision.

Experience With PAsTwenty-six health professions are regulated under Ontario’s Regulated

Health Professions Act, 1991 and health profession Acts (i.e., Medicine

Act, 1991).120,121 However, PAs remain unregulated in Ontario as HPRAC

concluded in 2012 that the practice of the PA profession did not pose

a substantive risk of harm to the health and safety of Ontario patients

and that “public safety and quality of care are sufficiently upheld at

this time through the delegation model and a regulatory registry.”122

HPRAC proposed a compulsory PA registry and recommended that

the College of Physicians and Surgeons of Ontario (CPSO) provide

governance and oversight.123 Medical care provided by PAs must be

supervised by a physician registered with CPSO and follow a process

of delegation. CPSO establishes the process for delegation of controlled

acts that physicians should follow when working with any non-physician

practitioners, including a PA.124 As of 2017, most of Canada’s practising

PAs were located in Ontario.125

Education ProgramsOntario houses two of the three civilian education programs and has the

majority of Canada’s medical providers. in 2008, McMaster University’s

first cohort of PA students started their studies, followed in 2010 by

119 Except for physicians who work under a salaried funding model, most often as part of family Health Teams in a CHC setting; in this instance, LHins provide funding.

120 Regulated Health Professions Act, 1991.

121 Regulated health professions include audiology and speech language pathology, chiropody and podiatry, chiropractic, dental hygiene, dental technology, dentistry, denturism, dietetics, homeopathy, kinesiology, massage therapy, medical laboratory technology, medical radiation technology, medicine, midwifery, naturopathy, nursing, occupational therapy, opticianry, optometry, pharmacy, physiotherapy, psychology, psychotherapy, respiratory therapy, and traditional Chinese medicine and acupuncture. Medicine Act, 1991.

122 Health Professionals Regulatory Advisory Council, The Health Profession Assistant, 38.

123 ibid.

124 College of Physicians and Surgeons of Ontario, Delegation of Controlled Acts.

125 CAPA 2017 membership database.



the first cohort of Consortium of PA Education Program students

(the Consortium is a collaboration between the University of Toronto,

The Michener institute of Education at the University Health network,

and the northern Ontario School of Medicine). Both programs are

accredited by the Canadian Medical Association Conjoint Accreditation

process and annually graduate approximately 50 PAs. The CAf PA

program (although more of a “national” than provincial program) is also

accredited by the Canadian Medical Association. its 2017 graduate

cohort is 15, although it has produced roughly 20 to 25 graduates per

year in the past. Outsourcing the PA program has been discussed.

Funding Sourcesfunding sources that enable the integration of PAs in Ontario function

as a patchwork of different mechanisms that depend on a variety

of factors that affect most other health care providers (e.g., the PA’s

employment setting, experience and skills, relationship with supervising

physician, the physician’s funding model, and resources to access

provincial grant programs). in 2007, Ontario funded employers to hire

PAs for demonstration project positions. PAs began working in hospitals

and, soon after, in CHCs. PAs in the demonstration project worked in

physician offices, long-term care homes, and diabetes care settings.

in the final phase, PAs were hired by additional hospital emergency

departments and family health teams. Evaluations commissioned by the

Government of Ontario found that employing PAs in a variety of settings

reduced wait times, improved patient satisfaction, increased supervising

physicians’ daily billings, increased home and long-term care referrals,

reduced acute-care stay lengths, and reduced long-term care residents’

alternate level-of-care days.126 funding for the demonstration project

positions ended in September 2015.

As of 2017, MOHLTC continues to provide time-limited funding to

support the transition of new PA graduates into the health care system

through the PA Career Start program (PA CSP). PA CSP supports the

employment of Ontario PA education program graduates “in areas of

126 fréchette and Shrichand, “insights into the Physician Assistant Profession in Canada”; Ministry of Health and Long-Term Care, Ontario Physician Assistant Implementation.



high priority … in a variety of settings including emergency departments,

primary care and internal medicine.”127 Employers may apply for a

PA CSP grant of up to $46,000 per year128 to assist them with costs

such as recruitment, salary/benefits, overhead, start-up, orientation,

and integration. There is a 50/50 cost share split between the employer

and MOHLTC. Eligible employers in northern and rural communities

or in communities with an Ontario Medical Association Rurality index

for Ontario (RiO) score of 40+, or a northern Urban Referral Centre

(Timmins, north Bay, Sudbury, Thunder Bay, Sault Ste. Marie) may

receive funding ($46,000) for two years.129 An additional $10,000

incentive is offered to PA graduates who complete one year of service

with employers who qualify for two years of funding (i.e., rural sites).130

Other eligible employers may receive grant funding for a period of

one year.

Only employers that meet specific criteria may be approved to receive

financial supports through PA CSP. for instance, employers must

demonstrate a commitment to integrate and sustain the PA position

beyond CSP funding. Employers receiving PA CSP grants must intend

to employ the PA after CSP funding ceases and provide assurances

that they have secured necessary finances to supplement the grant

funding before receiving the grant.131 HealthforceOntario’s Marketing

and Recruitment Agency monitors the applicants and conducts surveys

for an additional year once funding ceases. in the forthcoming Ontario

Physicians Assistants and Local Health Integration Network 2016 report,

of the 115 PAs surveyed, 23.5 per cent cited funding challenges and

15.7 per cent cited the elimination of the position as the reason they

had to change jobs.132 (See Chart 1.)

127 HealthforceOntario, 2017 Physician Assistant Career Start Program Guidelines.

128 ibid.

129 ibid.

130 HealthforceOntario, 2017 Physician Assistant Career Start Program Guidelines.

131 ibid.

132 O’Leary and Kohout, Ontario Physician Assistants and Local Health Integration Networks.

Only employers that meet specific criteria may be approved to receive financial supports through PA CSP.



Since 2012, integrating PAs into new and existing models of care

and clinical services funding has been under way. As a result, PAs

are funded by clinical service in primary care and hospital settings

across Ontario. for example, permanent PA positions are funded

annually in select family health teams and CHCs. Ontario also funds

PA positions to increase neurosurgery human team capacity. Other

Ontario PAs are employed by hospitals either through the CSP or

hospital budgets. (See Chart 2 for a funding breakdown of surveyed

Ontario PAs.)

The Patients First: Action Plan for Health Care133 exemplifies Ontario’s

commitment to put people and patients at the centre of the system by

focusing on putting patients’ needs first. To that end, MOHLTC is looking

to undertake initiatives that focus on building a whole health workforce

that is truly responsive to the needs of patients, whoever they are and

wherever they may be in the province. MOHLTC recently established

a Physician Assistant integration Working Group to support and

133 Ontario Ministry of Health and Long-Term Care, Patients First.

Chart 1Reasons for PA Job Changes(n = 148; per cent)

*Reported sub-catagories include researcher role (n = 1), non-clinical PA role (n = 1), and lack of PA role understanding in location (n = 1).Source: O’Leary and Kohout.

Other, please specify*

Can’t find a PA job

Pursuit of additional education

PA retirement

Employed as a PA or other type of educator

Maternity leave

Not working as a PA

PA practice interest outside of family practice

Non-military relocation

Military relocation, deployment, or retirement

Elimination of position

Location of position

Funding challenges

0 5 10 15 20 25



implement initiatives that improve population health with the integration

of more PAs into Ontario’s health workforce. Ongoing research

supports the expansion of PAs in Canada’s health workforce to improve

access, quality of care, and health system navigation in a variety of

health settings.134

Comparison of PA Funding Models Across Case Examples

The U.S. has the most experience in PA integration in states and various

large government administrative operations. Collectively, PAs and nPs

now account for 20 per cent of its health care workforce and the number

of annual graduates exceeds medical school graduates.135 While PA use

is more recent in the U.K. and the netherlands, it too is spreading rapidly

to accommodate health reform priorities. The three international case

examples highlight a variety of strategies for policy-makers, researchers,

and decision-makers about furthering PA integration in Canada.

134 McCutchen, Patel, and Copeland, “Expanding the Role of PAs in the Treatment of Severe and Persistent Mental illness.”

135 isolated PA data are not available from this source.

Chart 2Funding Sources for PA Positions, 2016(n = 148; per cent)

Note: The instrument return rate was 43.7 per cent (136 respondents for 311 Ontario PAs).*Identified subcatagories include no LHIN funding, not working as a PA, community health centre, pay for performance, foundation, private community donation, private industry, and unsure.Source: O’Leary and Kohout.

Other funding* (n = 25)

University funding (n = 1)

Research grants (n = 3)

Current grant extension (n = 3)

Military funding (n = 5)

Family health team funding (n = 19)

Department funding (n = 24)

New starter grants (n = 31)

Hospital funding (n = 36)

Physician funding (n = 39)

0 5 10 15 20 25 30



Table 3 is a comparison of case example funding models across

several characteristics, including the number of PAs working, general

organization of the health system, practice settings, patient population

profile, guiding legislation and/or regulation landscape, scope of practice,

source(s) of funding for PAs, average remuneration, and other features.

Table 3Comparison of Funding Model Characteristics—the U.S., U.K., Netherlands, Manitoba, and Ontario

Characteristic U.S. U.K. Netherlands Manitoba Ontario

Number of PAs • 100,000+ PAs across all states

• PAs and nPs comprise 20 per cent of the U.S. clinician workforce

• 288 PAs• 577 student PAs• The U.K. government

intends to develop 1,000 primary care-based PAs by 2020

• Approximately 1,000 PAs• five PA programs

produce 150 graduates per year

• 81 PAs• One PA program

produces 12 graduates per year

• 380 PAs• Two PSE PA programs

produce 50 graduates per year

Health system overview

• Per capita heatlh expenditures of $9,892 or 17.2 per cent of GDP

• in 2010, the Patient Protection and Affordable Care Act (ACA) created responsibility for health insurance among government, employers, and individuals

• ACA established 10 essential benefit categories (e.g., hospital services, maternal and child, etc.)

• The range of services within essential categories is determined by each state

• in 2015, 9.1 per cent of Americans were uninsured


• nHS centrally oversees the U.K. health system

• The Department of Health oversees stewardship of this universal health system

• The nHS manages budget and 209 local Clinical Commission Groups

• England is split up into 13 local areas, each area given flexibility for local funding model


• The Dutch health system runs centrally—the national government determines and monitors health care priorities and legislation

• Health services are provided through social health insurance

• 78 per cent of curative services are publicly financed

• All residents must purchase statutory health insurance from private insurers

• Per capita heatlh expenditures of $7,120 or 42 per cent of provincial budget

• The Ministry of Health, Seniors and Healthy Living provides funds to five regional health authorities

• it also maintains centralized structures like CancerCare Manitoba and Diagnostic Services

• PA allocation is centralized with the establishment of a provincial director

• Physicians provide supervision

• Per capita heatlh expenditures of $6,144 or 41 per cent of provincial budget

• MOHLTC provides funding to 14 LHins

• LHins are responsible for health care services, planning, and funding for hospitals, CACs, community support services, CHCs, and additctions and mental health services

• CPSO registers the physicians who supervise PAs and issues policy regarding delegation, medical directives, etc.

• PAs are supervised by physicians

Practice settings currently employing PAs

• PAs work in family medicine/general practice, surgical sub-specialties, and emergency medicine

• They practise in all 12 settings, including primary care, mental health, and anesthesiology

• They primarily work in private practice (39.8 per cent) and hospitals (37.3 per cent)

• PAs are employed across wide range of specialist areas, in over 35 different U.K. nHS acute hospital trusts and about 35 primary care settings

• in hospitals, PAs work mostly in general adult medicine and surgical specialties

• PAs work in all health care settings, from forensic to academic; however, most are employed in hospitals, followed by primary care

• no PAs are employed in the military

• PAs work in surgery, emergency, primary care, cardiac sciences, internal, pediatric, education, psychiatry, rehabilitation, oncology, and critical care

• They primarily work in private practice or are hospital-based

• PAs work in family medicine, primary care, emergency medicine, orthopedic surgery, general surgery, cardiology and cardiac sciences, critical care, general surgery, neurosurgery, etc.

• They primarily work in private practice or are hospital-based

(continued …)



Table 3 (cont’d)Comparison of Funding Model Characteristics—the U.S., U.K., Netherlands, Manitoba, and Ontario


Patient population profile

• Population of 316 million• 2.6 physicians practising

per 1,000 population• 4 average physician

visits per capita

• Population of 64 million• 2.8 physicians per

1,000 population

• Population of almost 17 million

• 3.5 physicians per 1,000 population

• 8.2 average physician visits per capita

• Population of 1.3 million• 2.04 physicians per

1,000 population

• Population of 13.9 million 2.2 physicians per 1,000 population

Guiding legislation and/ or regulation

• integrated since 1974• in 2010, the ACA

recognized PAs as primary care providers

• PAs can lead patient-centred medical teams

• Most states do not require PAs to be supervised under the same roof as a physician; however, a physician must be named

• PAs are not currently regulated

• in 2003, the U.K. introduced U.S.-trained PAs to augment primary care practices; the profession has grown with U.K.-trained PAs since then

• nHS HEE, nHS England, and workforce leads from Scotland (nHS Grampian), northern ireland, and Wales are working collaboratively with the Department of Health, General Medical Council, the Royal College of Physicians faculty of Physician Associates, and key national stakeholders to progress discussions around statutory registration

• Legislation for PAs is the most advanced worldwide

• Legislation also covers reimbursement by insurance companies

• PAs are regulated as independent health care providers

• PAs were regulated as clinical assistants (CAs) from 1999 to 2009

• now they are regulated as PAs under the Medical Act

• PAs operate in a physician extender role with direct supervision

• PAs are Associate Regulated Members of the College of Physicians and Surgeons of Manitoba

• All PAs require an approved Practice Description and Contract of Supervision before being allowed to practise medicine

• Ontario PAs are unregulated

• PAs are overseen by supervising physicians according to medical directives

• The Patients first: Action Plan for Health Care provides guiding principles

• The Canadian Medical Association’s 2012 Toolkit provides useful resources

Scope of practice • Scope of practice is determined at the practice level by physicians, as stipulated by the American Academy of Physician Assistants

• PA practice laws include licensure as the regulatory term, full prescriptive authority, adaptable collaboration requirements, chart co-signature requirements determined at the practice level. The number of PAs a physician may supervise is determined at the practice level.

• Scopes of practice across states are similar

• Scope of practice is similar to a junior physician

• PAs cannot prescribe or order CT or x-rays

• PAs can complete patient history and physical examination to determine diagnosis, develop a patient management plan on behalf of supervising physician, provide clinical management of a patient on behalf of supervising physician, and request and interpret diagnostic studies

• They can provide patient education, counselling, and health promotion

• Scope of practice reflects the PA’s specialty; PAs choose their specialty at the outset of their education and work under a supervising physician in a work-study model throughout their training

• PAs conduct low or moderately complex medical tasks within certain specialties, both in primary and secondary care

• PAs are authorized to indicate and perform predefined medical procedures and prescribe medications without supervision

• PA scope of practice will be re-evaluated in 2017

• Scope of practice mirrors that of their physicians with permission to perform restricted acts, provide prescriptions, or write medical orders established by regulations and provincial law

• PA scope of practice includes diagnoses, obtaining medical histories, performing physical exams, ordering and interpreting diagnostic studies, providing therapeutic procedures, prescribing medications, and educating and counselling patients

• PA scope of practice mirrors that of supervising physicians, including obtaining medical histories, performing medical exams, ordering and interpreting diagnostic studies, providing therapeutic procedures, prescribing medications, and educating and counselling patients

(continued …)



Table 3 (cont’d)Comparison of Funding Model Characteristics—the U.S., U.K., Netherlands, Manitoba, and Ontario


Source(s) of funding for PAs

• Remuneration from payers for PA services is typically through ffS model, often 85 per cent of physician’s fee schedule

• PA billing fees go through the physician or hospital corporation with whom they work; they are not sole entrepreneurial PAs

• The salary comes out of these billings

• nearly all payers cover PA services

• PA salary funding comes from nHS employers

• Because local clinical groups can allocate their funding as they choose, HEE is looking to incentivize PA recruitment in primary care with local teams able to target investments based on local priorities

• PAs receive a salary from the hospital

• The hospital invoices the insurance companies which then pay the hospital

• insurance companies negotiate with boards of hospitals for contracted services

• PAs can bill insurance companies directly

• Currently, there are no set fees for PAs by insurance companies

• Recently, the government shifted salary funding for PAs from hospitals to physician groups, which are now responsible for funding PA positions

• Previous funding covered 12 new positions each year through regional health authorities

• Physician groups may recoup costs for the PA by shadow billing or redirecting preexisting program funding

• Demonstration projects existed (until 2011)

• Ministry funding is provided for select family health teams, community health clinics, and other primary care enrollment models

• Other funding comes from physician salaries/practice overhead

• The government provides Career Start Program grants of up to $46,000, for one (regular) to two (Rurality RiO score of 40+ or a northern Urban Referral Centre) years, with an additional $10,000 incentive

• Clinical service funding is provided in primary care and hospitals

Average remuneration

• Salaried• US$95,000 median

salary from 2000 to 2013• Wages increased by

40 per cent compared with cumulative inflation rate of 35.3 per cent

• Salaried• not linked to volume

or type of patient seen• Typical remuneration

ranges from £33,000 to £42,000 per year

• Salaried• Each PA negotiates his

or her salary• The Dutch Health Care

Authority (nederlandse Zorgautoriteit) determines most provider fees, with €80,000 as the average annual salary

• in 2012, self-employed GPs earned an average gross annual income of €97,500

• Salaried• $75,000 to $120,000

per year• PAs and CAs organized

into one collective bargaining unit

• Salaried• $75,000 to $120,000

per year

Other features • Revenues generated by PAs in rural settings can create employment opportunities and wages, salaries, and benefits for staff, which are circulated through economy

• An increasing number of rural hospitals are choosing to staff PAs and nPs

• Critical mass of PAs facilitates general population acceptance and knowledge of PA role

• Uniquely among U.K. clinical professions, PAs are required to re-certify every six years, retaking their final exams

• A 2015 change in the tax system has facilitated the integration of PAs; medical specialists are typically considered independent health care contractors and are able to deduct practice expenses (40 per cent of gross income)

• To keep this tax-deducting privilege, these specialists need to hire other health professionals to form health care teams

• The province will be rolling out a province-wide tracking system to log data on each patient encounter

• This system will log every task and interaction and PA undertakes

• The tracking system will produce a data set to assist in planning, forecasting, and research

• A Physician Assistant integration Working Group was formed to help integrate PAs into Ontario’s health workforce



CHAPTER 4

Ontario PA Funding Experiences by Practice Setting

Chapter Summary

• The personal experiences of nine Ontario PAs working in primary care, emergency medicine, endocrinology, and orthopedic surgery provide insight into some of the opportunities and challenges associated with PA funding.

• A lack of stable funding is one of the main factors limiting the integration of additional PAs in the health workforce.

• Potential funding solutions include governments or LHins providing permanent PA salary funding or the introduction of special PA billing codes in an ffS model.

• if emerging patterns continue, much of the demand for PAs will remain or be expanded in the settings of emergency medicine and primary care.



To gain a greater understanding of some of the opportunities and challenges associated with PA funding experiences in Canada, the Conference Board interviewed nine Ontario health professionals (PAs and those with direct experience in funding PAs) working in primary care, emergency medicine, endocrinology, and orthopedic surgery.

Written questionnaires and funding documents (e.g., hospital

remuneration agreements and applications for government funding)

also provided supplementary data. in some cases, the personal

perspectives, opinions, and experiences of these interviewees speak

to the broader issues PAs in other jurisdictions are also facing. This

second round of interviews allowed for a richer context in which

to compare successes from Manitoba, the U.S., the U.K., and the

netherlands with Ontario’s variable funding experience.

Primary Care

in 2015, 13,442 physicians worked in family medicine in Ontario (98 per

100,000 population).1 As of july 2017, about 100 PAs (or about one-third

of Ontario’s PAs) were working in family practice.2 in the primary care

setting, PAs consulted for this work reported working within CHCs

and fHTs, or were hired privately by physicians.3 CHC and fHT PAs

are interprofessional team members alongside a variety of health

care providers (e.g., physicians, dietitians, nurses). fHTs were first

introduced in Ontario as part of primary care reform a little over 10 years

ago from ffS family medicine practices. Since 2005, 184 fHTs have

been operationalized, and these teams serve over 200 communities.4

1 Canadian Medical Association, Family Medicine Profile.

2 Association of family Health Teams of Ontario, Physician Assistants.

3 This section highlights the funding experience perspectives of the PAs/supervising physicians selected to participate in the interviews and is not necessarily representative of all PAs working in these settings.

4 Ontario Ministry of Health and Long-Term Care, Family Health Teams.



Ontario’s 184 fHTs employ 33 PAs5 to deliver acute care as well as

chronic disease management.6 Originally funded through pilots and

Career Start funding, MOHLTC added PAs to the list of providers

permitted to be funded through fHTs. in turn, these programs can

use existing funding to add new PAs to the complement of staff.

The number and types of health providers in an fHT is dependent upon

the business and operational plans submitted for approval. in turn, the

number relies upon the number and characteristics of patients served

by that fHT.7 fHT non-physician service providers, including PAs, are

salaried. A total of 74 CHCs serve approximately 500,000 people, with

250,000 of these accessing primary care services.8 CHCs have an

expanded scope of health promotion, outreach, and provide community

development services with the employment of interdisciplinary teams.

As Ontario demonstration projects ended in 2011,9 to justify a new

PA position, the fHT or CHC (for MOHLTC or LHin funding) needs a

business case that shows how patients will benefit. Without other funding

structures in place, CHC budget or fHT position funding often requires

rostering more patients or having physicians pay and determine how

to be reimbursed for PAs. Our consultations showed that PAs were

more likely to have secured funding if they were part of a CHC or fHT.

Province wide, there are approximately seven CHC PAs.10 Within a CHC,

some LHins flow money to select CHCs for an approved PA position.

These PAs are paid a salary that is funded through their respective LHin

as a permanent provider.

5 CAPA 2017 membership database. As an unregulated profession, tracking, validating, or accurately reporting where PAs are working across Canada can be difficult. While voluntary, CAPA’s membership and census data provide the most accurate information available.

6 fernando Tavares (Acting Program Manager, fHT Unit, Ministry of Health and Long-Term Care), telephone interview by Kelly Grimes, november 4, 2016.

7 Dinh, Improving Primary Health Care Through Collaboration: Briefing 1.

8 Association of Ontario Health Centres, CHC Fact Sheet.

9 The PA role was announced in May 2006 with the launch of HealthforceOntario, the government’s health human resources strategy. The PA initiative was co-led by MOHLTC and the Ontario Medical Association. The PA role was introduced to the Ontario health care system through a series of demonstration projects in different care settings (hospitals, primary care, diabetes, and long-term care). funding for PA roles through the demonstration projects ended in March 2011.


A total of 74 CHCs serve approximately 500,000 people, with 250,000 of these accessing primary care services.



As part of the demonstration projects, employers understood that

funding from Ontario was time limited. After the demonstration project

funding ended, it was the employer’s decision whether or not to hire the

PA as a permanent employee. Some LHINs ended up extending PA

funding multiple times before deciding to provide permanent funding

for a PA after the initial demonstration project concluded. Sustained

funding for PAs in the CHC and FHT settings provides a high level of job

security and allows PAs to be fully integrated in the health care teams.

As numerous studies indicate strong support for PAs among both health

care providers and the public,11 many CHC and FHT health providers

would like to see additional lines of stable support to fund more than

one PA per centre.

Emergency Medicine

Over the past seven years, annual Emergency Department (ED)

visits in Ontario have increased by 13.4 per cent (over double the

province’s 6.2 per cent population increase).12 In 2014–15, Ontario

EDs dealt with approximately 5.9 million patient visits. In 2015,

Ontario had 305 physicians working in emergency medicine (2.2 per

100,000 population).13 As of July 2017, 50 PAs are working in emergency

medicine.14 In Ontario, there are about 7 FFS ED physicians and

137 Alternate Funding Arrangement (AFA) ED physicians. Consulted

PAs reported working both in large academic hospital settings and

in small community hospitals as front-line providers in the ED. In an

academic hospital, PAs may take part in clinical activities in the

emergency room of more than one hospital within the same network.

In this setting, PAs may work with more than 80 physicians across

multiple sites. Emergency medicine PAs conduct both clinical and

non-clinical tasks. Non-clinical activities may include participating

11 See Dunlop, “A Team Designed to Meet Patient Needs”; Taylor and others, “Qualitative Study of Employment of Physician Assistants”; Doan and others, “The Role of Physician Assistants in Pediatric Emergency Medicine”; Nanos Research, Physician Assistants Project Summary; Doan and others, “Canadians’ Willingness to Receive Care From Physician Assistants”; Doan and others, “Parents’ Willingness to Have Their Child Receive Care by Physician Assistants in a Pediatric Emergency Department.”

12 Health Quality Ontario, Under Pressure.

13 Canadian Medical Association, Emergency Medicine Profile.


FuNDINg MODELS FOR PHySICIAN ASSISTANTSCanadian and International Experiences


in or leading patient improvement committees, or being involved in

an academic scholarship, including research, clinical supervision of

PA students, and university teaching.

Physician salaries are not part of the hospital global budget, yet PA

salaries are. under the ED Ontario demonstration project and Career

Start programs, PAs were/are hospital employees, and the source of

the salary may be the hospital (global budget or grants), the physicians

(billings or department funds), or a blend. In the community hospital

setting, the PA salary and benefits were supported by the hospital’s

budget.15 Overall, PAs in this context reported feeling a relatively high

level of job security, but also noted that their funding was never ironclad,

as all hospital employees could be subject to unexpected hospital

budgetary cuts.

Similarly, in an academic hospital setting, the informant PAs reported

feeling relatively secure in their positions, despite the fact that grant-

funding is not intended to be a permanent salary source. In this setting,

the interviewed PAs described the importance of departmental support

and commitment to securing an annual departmental budget line for PAs.

The interviewed PAs felt their role was valued and enjoyed a higher level

of job security than PAs working under FFS physician-funding models.

At the same time, however, the interviewees expressed reservations

surrounding the long-term sustainability of funding provided through

a physician’s Alternative Payments Program.

While the interviewed PAs in hospital emergency medicine settings

believed they enjoyed relative job security compared with PAs in other

sectors, they still identified significant challenges to the sustainability

and predictability of their current funding sources since there is no

direct or guaranteed funding source for PAs or other non-physician

employees. The PAs saw opportunities for funding stability under a

model like the one used to compensate physicians with whom they work

(e.g., under a FFS PA funding model, the PA would bill at a subsidized

rate similar to that in the u.S.). The emergency medicine PAs advocated


Physician salaries are not part of the hospital global budget, yet PA salaries are.



for sustainable funding models across clinical settings. it is important

to note that different funding envelopes mean that PAs cost the hospital

directly, whereas ER physicians do not.

Endocrinology

Approximately 193 physicians worked in endocrinology/metabolism

in Ontario in 2015 (1.4 per 100,000 population).16 As of july 2017,

at least eight PAs were working in endocrinology.17 The informant

PA in this field reported working in a private practice specialist group

with a multidisciplinary team, including physicians, dieticians, nurses,

chiropodists, diabetes educators, and pharmacists. These specialist

groups focus their services on a specific patient population (e.g., diabetic

patients). in this setting, the PA reported taking patient histories and

performing physical exams, treating diabetic patients alongside their

supervising physician; reviewing lab and diagnostic imaging; alerting

the supervising physician or contacting the patient with lab results;

conducting ongoing education with other PAs; and acting as sub-

investigators on medical trials within their clinic. The PA reported

working under medical directives that were first developed during

a PA pilot project in the clinic. Each year the medical directives are

reviewed and modified to fully reflect the diabetology PA role. Upon

annual modification, the medical directives are reviewed and signed

by the supervising physicians.

This endocrinology specialist group practice has two different ways of

supporting a PA salary. The initial salary source included a CSP grant

and the supervising physician’s ffS income, as part of the practice

overhead. To ease the financial burden, a PA’s salary may be shared

among several practice physicians. The PA had monthly targets for the

number of patients needed to be seen with his supervising physician

to ensure that the position was cost-equalizing for the practice. This

example demonstrates the success of the CSP grant option. The PA

was able to prove to the physician employers that he was able to meet

16 Canadian Medical Association, Endocrinology/Metabolism Profile.

17 CAPA Ontario records.



pre-established benchmarks and demonstrate long-term sustainability.

Based on this evidence, the physicians continued funding the PA through

revenue generated from ffS.

However, the PA interviewed did not believe that funding was secure in

either phase. Under the initial grant, the PA felt no sense of permanence

even if patient access increased and clinic flow and care improved. in the

ffS funding source scenario, the PA related that his position would be

jeopardized if the predetermined monthly patient quota was not met.

This PA specifically referenced the U.S. funding model as a viable and

sustainable solution to current funding challenges as he would be able to

increase patient volume and thus job security. However, PA billing codes

like the U.S. model or physicians billing a discount code for the service

provided by the PA would also require adjustments to the billing fee

legislation governing the Schedule of Benefits.

Orthopedic Surgery

in 2016, 604 physicians worked in orthopedic surgery in Ontario

(4.4 physicians per 100,000 population).18 in an orthopedic surgery

setting, the consulted PA reported working in outpatient clinics alongside

a supervising physician in an ffS physician-funding model. Barriers

in securing hospital privileges have hindered orthopedic surgery PAs

in joining their supervising physicians in the pre- or post-op, admitting

emergency room orthopedic patients to the hospital, or assisting with

operating room or hospital-based fracture clinics. As such, PAs in

this setting typically work alongside the supervising physician in their

outpatient clinic on non-hospital days.

in orthopedics, supervising physicians typically work in an ffS model,

which means they are responsible for funding the PA as part of their

staff. A key informant noted that PA positions in private practice are

usually advertised at an hourly rate of $40 but, depending on the

supervising physician’s preference, a salary may be offered in place

of an hourly rate. in either case, the PA’s funding is included in the

physician’s practice overhead. The willingness and ability of physicians

18 Canadian Medical Association, Orthopedic Surgery Profile.



to fund a PA is influenced by how the physician values the PA’s

contributions to the practice and whether the financial means exist

to cover the cost.

CAPA 2017 census data show that 83.44 per cent of Canada’s

PAs are employed full time, 6.37 per cent are employed part time,

9.55 per cent are unemployed, and 0.64 per cent are retired.19 Like

other health care providers, some PAs work several part-time positions

under different physicians to create a 40-hour work week (e.g., a PA

may work three weekdays under a primary supervising physician in

orthopedic surgery and supplement another two days under a physiatrist

or other physician). This arrangement brings both opportunities and

complications. On one hand, working multiple part-time jobs is not

unique to PAs or the health workforce. Many physicians work in a

variety of clinical settings in any given week, which provides new grads

with the opportunity to work in various settings and learn from different

physicians. A model in which a hospital employee PA also works

clinically in a variety of specialties could help divide up the PA’s salary

cost among different departments. On the other hand, this situation

could bring complications surrounding benefits, such as extended

benefits and vacation time. The trend toward working several part-time

positions was mostly observed among PAs working with physicians in

an ffS model, such as orthopedic PAs working in outpatient clinics.

PAs in this setting pieced together as many as three different hourly

waged positions in separate care settings to generate what would be

equivalent to a full-time salary.

Opportunities and Challenges

interviewees identified lack of funding as the main factor that limits

opportunities and presents hiring challenges in any given setting or

location. Potential solutions include having the provincial government

or LHins provide funding for permanent PA salaries, allowing physicians

to bill for a PA under a special billing code, or giving PAs a billing number

and allowing these providers to bill at a subsidized rate, similar to that


interviewees identified lack of funding as the main factor that limits opportunities.



in the United States. The interviewees identified a lack of regulation

and legislation as the second-largest challenge that impacts PAs’

ability and opportunity to work in a variety of practice settings. Other

identified challenges include unclear guidelines about integrating a PA

into the practice, skills, training, experience, and government priorities.

if emerging patterns continue, much of the demand for PAs will remain in

or be expanded in the settings of emergency medicine and primary care.


CHAPTER 5

Conclusion

Chapter Summary

• Although largely an area of untapped potential in most provinces and territories, PAs can help address many service gaps and health system policy goals, including improved continuity care, access, equity, and sustainability.

• PAs can be an efficient extender or complement for designated medical tasks, alleviating demand on physicians’ time and improving patient care.

• A comprehensive funding model would enable the expansion of PAs across Canada.

• A tracking system showing evidence of impact within various funding models would help make the business case for the greater integration of PAs across jurisdictions that currently employ them and for consideration in others that currently do not.



Canada’s health system consumes a significant portion of the country’s economic resources. Population aging and the rise in chronic disease will continue the pressure to spend. Interprofessional and collaborative care teams can help meet heightened health services demand, and PAs can act as an efficient complement, or substitute for designated medical tasks. PAs can help meet a growing demand for medical services by providing additional resources for physicians to work on other tasks (e.g., clinical, teaching, research, or administrative). However, sustainable funding models that support PA employment and integration are lacking in many provinces, and the largest population of PAs remains unregulated in Ontario.

The international PA funding examples from the U.S., the U.K., and

the netherlands reveal that as demand for care increases, new and

innovative workforce planning and delivery models emerge to better

meet local needs. PAs are an effective and largely “untapped” health

provider group that can be part of solutions for needs-based planning.

Service delivery approaches must provide high-quality, efficient, and

effective (including cost-effective) care. PAs trained in the medical model

act as physician extenders in collaborative and interprofessional teams.

Optimizing the use of PAs can address many service gaps and health

system policy goals in Canada, including improved continuity care,

access, equity, and sustainability. PAs can address many of the nation’s

looming workforce gaps. Paradoxically, PA integration remains largely

an area of untapped potential in most provinces and territories.

The insights generated from interviews with several Ontario PAs

represent some unique experiences of PAs, including perspectives

on funding agreements, regulation, and medical directives. Ontario



has implemented some successful funding mechanisms, both in its

demonstration projects and its CSP. This continues with new clinical

services funding in primary care and hospital settings. Although it has

not yet developed a long-term sustainable PA funding model, it has

established a Physician Assistant Working Group to help the Ministry

of Health and Long-Term Care develop and implement initiatives to

improve the integration of PAs into Ontario’s health workforce for the

benefit of patients.

The funding experience of Ontario PAs is a patchwork of funding

mechanisms across and within practice settings. The interview

perspectives reveal a sentiment that the absence of a provincially

mandated funding model is a significant barrier to employment and

stability for Ontario PAs. Key informants highlighted the opportunity for

PAs to play a significant role in improving quality of care for Ontarians

by improving access to care. These opportunities, however, cannot

be wholly realized without a sustainable funding model, professional

regulation, awareness, and education. Suggested potential avenues

for exploration include the implementation of salaried funding and

the introduction of a subsidized PA billing code to the physician ffS

schedule. The PAs consulted in this work voiced that they would like

to see a sustainable funding model for PAs in Ontario to support the

longevity and growth of the profession in the province.

Some of the key observations and potential areas for further investigation

in future research and in the subsequent report of this series are

described below.

Funding Models Need to Better Reflect Context

The domestic and international funding sources vary widely and no “best

practice” funding model approach emerged. The context of where the

PA is employed, the services the PA is providing, the availability of funds,

and the incentives or disincentives resulting from that funding model and

how they affect cost-effectiveness and sustainability all impact the type

of funding mechanisms countries employ. for example, the U.K. is using

PAs to deal with locum issues, especially in rural/remote settings. This

strategy may not translate directly to the Canadian context, as physician

The domestic and international funding sources vary widely and no “best practice” funding model approach emerged.



services here come from a different funding envelope. The Dutch

experience shows that tax changes can be powerful motivators to

further PA acceptance and integration among physician groups.

A Salaried Approach for Remuneration Is the Most Common and Likely Way Forward

Salary appears to be the most common approach to PA remuneration,

which is set at a rate that is reflective of the PA experience and where

they are employed. in the international case examples from the U.S.,

the U.K. and the netherlands, and the domestic examples from Manitoba

and Ontario, most PAs are salaried; however, remuneration for their

services by public payers is often made through a discounted ffS

model (85 per cent) back to the delivery model. in Ontario, this funding

mechanism would require an adjustment to the Schedule of Benefits

for physicians to be able to recoup the costs by being able to bill for

the services rendered by their PA.

Monitoring PA Work, as Well as Their Impact, Outcomes, and Efficiency, Is Essential

An appropriate funding model for PA integration must be efficient and

sustainable for the health system and meet defined performance and

outcome targets. Pilot-testing of various approaches has been done, and

Canada needs to start implementing accountability metrics. Manitoba

believes that tracking based on either iCD-10 or physician ffS billing

codes might be a better method to understand PA tasks and impact.

A tracking system would also help build a database to undertake further

research on the quantitative impact of PAs in the Canadian health

system and to help monitor the ever-growing and evolving practices

across the country. This should include where and how they work and

how that changes with community needs and infrastructural challenges

and opportunities over time. improved data collection and tracking

systems would also benefit employers and funders of PAs. Opportunities

immediately arise in collaborative and comparative work models in the

U.S., U.K., and the netherlands to identify efficiencies of service delivery

to select populations.



Communication About the Value of PAs Is Important Within a Strained Health Care System

The optimization of the use of PAs in Canada within models requires

clear communication with health system administrators, policy-makers,

other health care providers, and—most importantly—patients.

All Canadians need to regard the role of PAs and the value they

bring to the health care system from a population health and efficiency

perspective. PAs must be seen to be filling service gaps in the health

care system. Evidence of where they can contribute to a system to

improve patient demands is needed. Although a number of studies and

project evaluation reports have demonstrated the PAs’ ability to improve

patient access and quality of care, as well as the work–life balance of

physicians and other health care providers, more granular research is

needed.1 While the HealthforceOntario project was the largest and best-

designed study of PAs to date, very little promulgation of the vast data

gathered has been published.

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APPENDIX A

Key Informant Interviews and Guide for Case Examples

Tables 1 and 2 show the key informants and the additional informants,

respectively, that took part in the 45-minute interviews.

Table 1Key Informants, Using Standardized Interview Guide

Country Informant

Canada (Manitoba) Russell ives, MPAS, CCPADirector (Provincial/WRHA)Physician & Clinical Assistant ProgramWinnipeg, Manitoba

United States Roderick S. Hooker, PhD, MBA, PAindependent Health Policy ConsultantAdjunct Professor northern Arizona University

United Kingdom Matt AielloUrgent and Acute Workforce Development Specialist,West Midlands, Health Education England

netherlands Wijnand van Unen, MPAPresident netherlands Physician Assistant AssociationUtrecht, netherlands


Table 2Additional Informants, Using Subsequent Telephone and/or E-mail Communications

Country Informant

Canada (Manitoba) ian W jones, MPAS, CCPA, PA-C, DfAAPAProgram Director; Assistant ProfessorMaster Physician Assistant StudiesMax Rady College of MedicineWinnipeg, Manitoba

(continued …)


Appendix A | The Conference Board of Canada

Table 2 (cont’d)Additional Informants, Using Subsequent Telephone and/or E-mail Communications

Country Informant

United Kingdom Tamara S. Ritsema MPH, MMSc, PA-CDirector of U.K. PA Annual national CensusWashington, D.C.

netherlands Ellen Dankers-de Mari*Physician Assistant en Verpleegkundig SpecialistCapaciteitsorgaanUtrecht, netherlands


Interview Guide Questions

Many thanks for agreeing to take 45 minutes to chat with us.

The Canadian Association of Physician Assistants (CAPA) has

commissioned The Conference Board of Canada to undertake this

project to provide a better understanding of the role and impact that

physician assistants (PAs) have had in various health care settings

across Canada, as well as a review of funding models that have enabled

the successful and sustainable integration of PAs in various health

systems. We are collecting data to better understand the various funding

models that have been implemented to integrate PAs into health care

teams: stand-alone salaries, fee-for-service, as well as fees that are

linked to physician compensation. it will identify funding options and

recommendations to engage in a practical dialogue toward the future

expansion of PAs’ role within health care systems across Canada.

To accompany a literature review, information from key informant

interviews both in Canada and in other systems with longer experience

using PAs are being conducted. Your name was provided by CAPA and/

or the advisory committee in our effort to gather perspectives. Would you

be willing to have your name and organization cited in this policy report?

Any questions before we begin?



Section A: Key Informant Interview Profilename of interviewer(s):

name of interviewee(s), title(s), organization name, and location:

Date of interview:

Section B: Background of the Context1. Briefly describe the settings in which PAs practise within your health

system (i.e., primary care, acute care, long-term care).

2. How long have PAs practised as part of your clinical teams?

3. How many PAs are currently employed in your context (total and

by setting)?

4. What roles do they undertake?

5. Are PAs regulated or outlined in legislation within your context? Why or

why not? What are their education requirements? What are their scopes

of practice?

6. Are you aware of the original impetus in deciding to integrate PAs in

your jurisdiction/clinical setting? if yes, what was it? Have your original

objectives changed over time?

7. Did you develop a business plan, impact study, or other background

documents to make the case for PA integration? if yes, what are

your most compelling arguments? Would you be willing to share

these materials?

8. What is the general acceptance of the PA role by other members of

the health delivery team? What have been some of the barriers and

facilitators to acceptance of PAs?

Section C: Funding Model for PAs9. What is the current funding model being used to integrate PAs into

health care teams (i.e., direct from government, regional health authority,

physicians, government project)? is the funding model sustainable in the

longer term?

10. How are PAs remunerated (salary, fee-for-service, other)? What is

the average annual salary for PAs? Would they be willing to provide

the salary grid and the average salary? How do PAs move through the

salary grid (i.e., is it annual increments or based on merit)?


Appendix A | The Conference Board of Canada

11. What are the advantages and disadvantages of this funding and

remuneration model?

12. Are there other funding models or considerations that should be

emulated in the future expansion of the PA’s role in health systems

to ensure more effective integration and optimization? Why suggest

this (i.e., consider around barriers and facilitators)?

Section D: Impact13. Have you examined if PAs provide a cost-effective solution to enhance

health care services? if so, what have you discovered? Any evidence

that PAs enhance physicians’ productivity (physician time saved, wait

times, length of appointment visit, length of stay, resident workload,

physician caseload)?

14. Do you have any other qualitative or quantitative data on the impact of

PAs on the organization in terms of outputs and outcomes, especially

around access (roster level, number of patients seen per day/week/

month, number of office visits per patient, etc.), or outcomes (cost

savings, patient satisfaction, employee satisfaction, safety, mortality,

indicators of care, etc.). Documentation/evidence that could be shared?

15. Any other advice, reports, or articles you would like to provide on funding

models and their potential impacts to better understand the role and

impact of PAs?



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